How clean is clean? Proposed methods for hospital cleaning assessment

Can the adenosine triphosphate (ATP) bioluminescence assay be used as an indicator for hospital cleaning? - A pilot study

Background

In hospital cleaning, there is currently no standard for uniform monitoring of surface cleaning, either in Germany or internationally. One possibility for monitoring is the use of so-called objective methods for checking cleaning performance (e.g. fluorescence or adenosine triphosphate (ATP) method).

Aim

The aim of the study was to monitor and evaluate the implementation of the adenosine triphosphate (ATP) bioluminescence assay as a cleaning indicator in everyday hospital cleaning, in order to verify its utility and effectiveness.

Methods

In three phases, five frequently touched surfaces were examined with the ATP bioluminescence assay at different time points. 846 measurements were performed on the dermatology ward of a university hospital (phase 1), 1,350 measurements were performed on five different wards of the university hospital (phase 2), and 1,044 measurements were performed on five wards of another large hospital (phase 3). For this purpose, one structurally old and one structurally new ward as well as an intensive care unit (ICU), an outpatient clinic and a radiology department were selected for phases 2 and 3.

Results

With the ATP bioluminescence method, we were able to demonstrate a reduction in values after cleaning: before cleaning mean of ATP, 907 relative light units (RLU) (95% confidence interval [CI] 777; 1,038); after cleaning mean=286 RLU (CI=233; 495) (phase 1) and by intervention (five hours after daily cleaning mean=360 RLU (CI=303; 428); five hours after daily cleaning and two additional cleanings mean=128 RLU (CI=107; 152) (phase 3). The ATP values increased five hours after cleaning in phases 1 and 2, and eight hours after cleaning in phase 3. The structurally old wards had the highest ATP content, the ICU and the radiology department, among others, the lowest. In all phases, door handles showed both a reduction after cleaning or intervention and a subsequent increase in ATP values. Chair armrests, examination tables and door handles had high ATP values overall.

Conclusion

The study shows ward differences both for cleaning effects and for the soiling characteristics of surfaces during the course of the day. In addition, it demonstrates the benefit of intermediate cleaning twice a day. It is noteworthy that structurally old stations and older inventory were more heavily soiled and, in some cases, more difficult to clean. The results show that the ATP bioluminescence method is suitable for detecting cleaning effects and can be used in everyday clinical practice for simple cleaning monitoring. Furthermore, it enables the detection of risk surfaces and easy-to-clean surfaces with significant re-soiling.

Hospital cleaning: past, present, and future

INTRODUCTION

The importance of hospital cleaning for controlling healthcare-associated infection (HAI) has taken years to acknowledge. This is mainly because the removal of dirt is inextricably entwined with gender and social status, along with lack of evidence and confusion over HAI definitions. Reducing so-called endogenous infection due to human carriage entails patient screening, decolonisation and/or prophylaxis, whereas adequate ventilation, plumbing and cleaning are needed to reduce exogenous infection. These infection types remain difficult to separate and quantitate. Patients themselves demonstrate wide-ranging vulnerability to infection, which further complicates attempted ranking of control interventions, including cleaning. There has been disproportionate attention towards endogenous infection with less interest in managing environmental reservoirs.

QUANTIFYING CLEANING AND CLEANLINESS

Finding evidence for cleaning is compromised by the fact that modelling HAI rates against arbitrary measurements of cleaning/cleanliness requires universal standards and these are not yet established. Furthermore, the distinction between cleaning (soil removal) and cleanliness (soil remaining) is usually overlooked. Tangible bench marking for both cleaning methods and all surface types within different units, with modification according to patient status, would be invaluable for domestic planning, monitoring and specification.

AIMS AND OBJECTIVES

This narrative review will focus on recent history and current status of cleaning in hospitals. While its importance is now generally accepted, cleaning practices still need attention in order to determine how, when and where to clean. Renewed interest in removal and monitoring of surface bioburden would help to embed risk-based practice in hospitals across the world.

Environmental contamination with highly resistant microorganisms after relocating to a new hospital building with 100% single-occupancy rooms: A prospective observational before-and-after study with a three-year follow-up

INTRODUCTION

Inanimate surfaces within hospitals can be a source of transmission for highly resistant microorganisms (HRMO). While many hospitals are transitioning to single-occupancy rooms, the effect of single-occupancy rooms on environmental contamination is still unknown. We aimed to determine differences in environmental contamination with HRMO between an old hospital building with mainly multiple-occupancy rooms and a new hospital building with 100% single-occupancy rooms, and the environmental contamination in the new hospital building during three years after relocating.

METHODS

Environmental samples were taken twice in the old hospital, and fifteen times over a three-year period in the new hospital. Replicate Organism Direct Agar Contact-plates (RODACs) were used to determine colony forming units (CFU). Cotton swabs premoistened with PBS were used to determine presence of methicillin-resistant Staphylococcus aureus, carbapenemase-producing Pseudomonas aeruginosa, highly resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and vancomycin-resistant Enterococcus faecium. All identified isolates were subjected to whole genome sequencing (WGS) using Illumina technology.

RESULTS

In total, 4993 hospital sites were sampled, 724 in the old and 4269 in the new hospital. CFU counts fluctuated during the follow-up period in the new hospital building, with lower CFU counts observed two- and three years after relocating, which was during the COVID-19 pandemic. The CFU counts in the new building were equal to or surpassed the CFU counts in the old hospital building. In the old hospital building, 24 (3.3%) sample sites were positive for 49 HRMO isolates, compared to five (0.1%) sample sites for seven HRMO isolates in the new building (P < 0.001). In the old hospital, 89.8% of HRMO were identified from the sink plug. In the new hospital, 71.4% of HRMO were identified from the shower drain, and no HRMO were found in sinks.

DISCUSSION

Our results indicate that relocating to a new hospital building with 100% single-occupancy rooms significantly decreases HRMO in the environment. Given that environmental contamination is an important source for healthcare associated infections, this finding should be taken into account when considering hospital designs for renovations or the construction of hospitals.

Toward a Comprehensive Domestic Dirt Dataset Curation for Cleaning Auditing Applications

Cleaning is an important task that is practiced in every domain and has prime importance. The significance of cleaning has led to several newfangled technologies in the domestic and professional cleaning domain. However, strategies for auditing the cleanliness delivered by the various cleaning methods remain manual and often ignored. This work presents a novel domestic dirt image dataset for cleaning auditing application including AI-based dirt analysis and robot-assisted cleaning inspection. One of the significant challenges in an AI-based robot-aided cleaning auditing is the absence of a comprehensive dataset for dirt analysis. We bridge this gap by identifying nine classes of commonly occurring domestic dirt and a labeled dataset consisting of 3000 microscope dirt images curated from a semi-indoor environment. The dirt dataset gathered using the adhesive dirt lifting method can enhance the current dirt sensing and dirt composition estimation for cleaning auditing. The dataset's quality is analyzed by AI-based dirt analysis and a robot-aided cleaning auditing task using six standard classification models. The models trained with the dirt dataset were capable of yielding a classification accuracy above 90% in the offline dirt analysis experiment and 82% in real-time test results.

The Evaluation of Electrolyzed Water, Sodium Dichloroisocyanurate and Peracetic Acid with Hydrogen Peroxide for the Disinfection of Patient Room Surfaces

BACKGROUND

Sporicidal disinfectants are necessary to control Clostridioides difficile and Candida auris. Novel application methods such as electrostatic sprayers may increase disinfection effectiveness. We employed a standardized protocol to assess three sporicidal disinfectants: electrolyzed water (EW), sodium dichloroisocyanurate (NaDCC) and peracetic acid/hydrogen peroxide (PAA/H₂O₂).

METHODS

The study was conducted at two New York City hospitals (1,082 total beds) over an 18-month period. The three chemicals were applied by housekeeping personnel following the hospital protocol; the use of electrostatic sprayers was incorporated into EW and NaDCC. In randomly selected rooms, five surfaces were sampled for microbial colony counts after cleaning. Data analyses were performed using negative binomial logistic regression.

RESULTS

We collected 774 samples. NaDCC-disinfected surfaces had a lower mean colony count (14 CFU) compared to PAA/H₂O₂ (18 CFU, p=0.36) and EW (37 CFU, p<.001). PAA/H₂O₂ and EW had more samples with any growth (both p<.05) compared to NaDCC. NaDCC applied with wipes and an electrostatic sprayer had the lowest number of samples with no growth and <2.5 CFU/cm² (difference not significant).

CONCLUSIONS

The use of NaDCC for surface disinfection resulted in the lowest bacterial colony counts on patient room high touch surfaces in our study.

The efficiency of cleaning in intensive care units: A systematic review

OBJECTIVES

This review aims to analyze the studies on cleaning practices and the efficiency of the cleaning carried out in environments that have a great risk of resistant microorganism infection, such as intensive care units.

METHODS

In this study, a retrospective literature review was undertaken of the relevant publications between the years 2005 and 2020, using the keywords "Cross Infection, Infection Control, Multidrug-Resistant Bacteria, Intensive Care, Room Cleaning, Environmental Cleaning, Hospital-Associated Infection"; using the international databases Pubmed, CINAHL and EBSCO and domestic database ULAKBIM on search engines. Titles and abstracts of all relevant articles found on electronic searches were reviewed by the researchers independently. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline and Patient, Intervention, Comparison, Outcomes, Study design model were used in analysing the studies.

RESULTS

The selected studies were reviewed in four main categories: Materials used in cleaning, the period between taking environmental samples, cleaning methods, and the efficiency of cleaning. Among the studies included herein, eight were randomized controlled trials, three were retrospective intervention studies, two were case-control studies and one was a retrospective cohort study.

CONCLUSIONS

Today, the assessment of cleaning in environments can be evaluated by different methods, but there are advantages and disadvantages of these methods. Therefore, in the relevant literature, it is suggested that cleaning must be evaluated by several methods, not only one. Also, training the staff that carries out the cleaning and rewarding correct behavior by giving feedback are important approaches to increase the efficiency of cleaning. It is suggested that cleaning must be carried out every day, regularly with effective methods and equipment; frequency of cleaning during epidemics must be increased, institutions must prepare cleaning manuals according to evidence-based guidelines that are recognized at an international level.

A Reinforcement Learning Based Dirt-Exploration for Cleaning-Auditing Robot

Cleaning is one of the fundamental tasks with prime importance given in our day-to-day life. Moreover, the importance of cleaning drives the research efforts towards bringing leading edge technologies, including robotics, into the cleaning domain. However, an effective method to assess the quality of cleaning is an equally important research problem to be addressed. The primary footstep towards addressing the fundamental question of “How clean is clean” is addressed using an autonomous cleaning-auditing robot that audits the cleanliness of a given area. This research work focuses on a novel reinforcement learning-based experience-driven dirt exploration strategy for a cleaning-auditing robot. The proposed approach uses proximal policy approximation (PPO) based on-policy learning method to generate waypoints and sampling decisions to explore the probable dirt accumulation regions in a given area. The policy network is trained in multiple environments with simulated dirt patterns. Experiment trials have been conducted to validate the trained policy in both simulated and real-world environments using an in-house developed cleaning audit robot called BELUGA.

Evidence Map and Systematic Review of Disinfection Efficacy on Environmental Surfaces in Healthcare Facilities

Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28-34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, and subsequently HAIs, in critical care settings. This evidence map includes a systematic review on the efficacy of disinfecting environmental surfaces in healthcare facilities. We screened 17,064 abstracts, 635 full texts, and included 181 articles for data extraction and study quality assessment. We reviewed ten disinfectant types and compared disinfectants with respect to study design, outcome organism, and fourteen indictors of study quality. We found important areas for improvement and gaps in the research related to study design, implementation, and analysis. Implementation of disinfection, a determinant of disinfection outcomes, was not measured in most studies and few studies assessed fungi or viruses. Assessing and comparing disinfection efficacy was impeded by study heterogeneity; however, we catalogued the outcomes and results for each disinfection type. We concluded that guidelines for disinfectant use are primarily based on laboratory data rather than a systematic review of in situ disinfection efficacy. It is critically important for practitioners and researchers to consider system-level efficacy and not just the efficacy of the disinfectant.

An Autonomous Robot-Aided Auditing Scheme for Floor Cleaning

Cleaning is an important factor in most aspects of our day-to-day life. This research work brings a solution to the fundamental question of “How clean is clean” by introducing a novel framework for auditing the cleanliness of built infrastructure using mobile robots. The proposed system presents a strategy for assessing the quality of cleaning in a given area and a novel exploration strategy that facilitates the auditing in a given location by a mobile robot. An audit sensor that works by the “touch and inspect” analogy that assigns an audit score corresponds to its area of inspection has been developed. A vision-based dirt-probability-driven exploration is proposed to empower a mobile robot with an audit sensor on-board to perform auditing tasks effectively. The quality of cleaning is quantified using a dirt density map representing location-wise audit scores, dirt distribution pattern obtained by kernel density estimation, and cleaning benchmark score representing the extent of cleanliness. The framework is realized in an in-house developed audit robot to perform the cleaning audit in indoor and semi-outdoor environments. The proposed method is validated by experiment trials to estimate the cleanliness in five different locations using the developed audit sensor and dirt-probability-driven exploration.

The efficiency of cleaning in intensive care units: A systematic review

OBJECTIVES

This review aims to analyze the studies on cleaning practices and the efficiency of the cleaning carried out in environments that have a great risk of resistant microorganism infection, such as intensive care units.

METHODS

In this study, a retrospective literature review was undertaken of the relevant publications between the years 2005 and 2020, using the keywords "Cross Infection, Infection Control, Multidrug-Resistant Bacteria, Intensive Care, Room Cleaning, Environmental Cleaning, Hospital-Associated Infection"; using the international databases Pubmed, CINAHL and EBSCO and domestic database ULAKBIM on search engines. Titles and abstracts of all relevant articles found on electronic searches were reviewed by the researchers independently. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline and Patient, Intervention, Comparison, Outcomes, Study design model were used in analysing the studies.

RESULTS

The selected studies were reviewed in four main categories: Materials used in cleaning, the period between taking environmental samples, cleaning methods, and the efficiency of cleaning. Among the studies included herein, eight were randomized controlled trials, three were retrospective intervention studies, two were case-control studies and one was a retrospective cohort study.

CONCLUSIONS

Today, the assessment of cleaning in environments can be evaluated by different methods, but there are advantages and disadvantages of these methods. Therefore, in the relevant literature, it is suggested that cleaning must be evaluated by several methods, not only one. Also, training the staff that carries out the cleaning and rewarding correct behavior by giving feedback are important approaches to increase the efficiency of cleaning. It is suggested that cleaning must be carried out every day, regularly with effective methods and equipment; frequency of cleaning during epidemics must be increased, institutions must prepare cleaning manuals according to evidence-based guidelines that are recognized at an international level.

Prevalence of extended-spectrum cephalosporin-, carbapenem-, and fluoroquinolone-resistant members of the family Enterobacteriaceae isolated from the feces of horses and hospital surfaces at two equine specialty hospitals

OBJECTIVE

To estimate the prevalence of extended-spectrum cephalosporin-, carbapenem-, and fluoroquinolone-resistant bacteria of the family Enterobacteriaceae in the feces of hospitalized horses and on hospital surfaces.

SAMPLE

Fecal and environmental samples were collected from The Ohio State University Galbreath Equine Center (OSUGEC) and a private referral equine hospital in Kentucky (KYEH). Feces were sampled within 24 hours after hospital admission and after 48 hours and 3 to 7 days of hospitalization.

PROCEDURES

Fecal and environmental samples were enriched, and then selective media were inoculated to support growth of Enterobacteriaceae bacteria that expressed resistance phenotypes to extended-spectrum cephalosporins, carbapenems, and fluoroquinolones.

RESULTS

358 fecal samples were obtained from 143 horses. More samples yielded growth of Enterobacteriaceae bacteria that expressed resistance phenotypes (AmpC β-lactamase, OR = 4.2; extended-spectrum beta-lactamase, OR = 3.2; and fluoroquinolone resistance, OR = 4.0) after 48 hours of hospitalization, versus within 24 hours of hospital admission. Horses hospitalized at KYEH were at greater odds of having fluoroquinolone-resistant bacteria (OR = 2.2). At OSUGEC, 82%, 64%, 0%, and 55% of 164 surfaces had Enterobacteriaceae bacteria with AmpC β-lactamase phenotype, extended-spectrum beta-lactamase phenotype, resistance to carbapenem, and resistance to fluoroquinolones, respectively; prevalences at KYEH were similarly distributed (52%, 32%, 1%, and 35% of 315 surfaces).

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that antimicrobial-resistant Enterobacteriaceae may be isolated from the feces of hospitalized horses and from the hospital environment. Hospitalization may lead to increased fecal carriage of clinically important antimicrobial-resistance genes.

Aptasensor for the detection of Methicillin resistant Staphylococcus aureus on contaminated surfaces

There is mounting evidence that contaminated hospital environment plays a crucial role in the transmission of nosocomial pathogens such as MRSA. The institution of infection control protocols is predicated on the early laboratory detection of the pathogen from relevant samples. Processing of environmental samples for the presence of bacterial contaminants in the clinical environment is poorly standardized when compared with analysis of clinical samples. The various laboratory methods available for processing environmental samples are difficult to standardized and most require a long turnaround time before results are available. In this study, we present a report of the performance of a novel pathogen aptasensor swab designed to qualitatively and quantitatively detect MRSA, on contaminated non-absorbable surfaces. The visual detection limit of the MRSA aptasensor swab was less than 100 CFU/ml and theoretically using a standard curve, was 2 CFU/ml. A relatively short turnaround time of 5 min was established for the assay while the linear range of quantitation was 10²-10⁵ CFU/ml. Engineered aptasensor targets MRSA selectively and binds to none of the other tested bacterial pathogen, on a multi-contaminated surface. This novel detection tool was easy to use and relatively cheap to produce.

An alternative approach for the decontamination of hospital settings

Background

The increasing emergence and spread of multiresistant microorganisms in hospital wards is a serious concern. Traditional protocols are often not sufficient to protect patients susceptible to serious and life-threatening infections, therefore new strategies for decontaminating hospital environments are crucial to reducing microbial transmission and the spread the nosocomial infections. The adoption of modern technologies is indicated to supplement traditional methods and to improve desired levels of surface disinfection.

Aim

This work aims to report the development, implementation, and validation of cleansing and sanitizing procedure for critical clinical settings through the innovative use of disposable cloths pre-impregnated with solutions containing different active formulations and biocidal agents, relating to the areas to be treated (low, moderate, high-risk).

Methods

The implementation and validation of the sanitizing system were conducted in different wards of two healthcare structures. The protocol for the study involved a structured selection of representative surfaces, such as the floor, bathroom, desk, and beds. Microbiological analyses were performed according to ISO 4833-1:2013.

Findings

The efficiency of the proposed system was measured through the estimation of total microbial count values on the different surfaces before and after the sanitization operations by traditional methods and by the system described here. The results demonstrated a significant reduction in the microbial count that always fell below the threshold value. For the analyzed surfaces such as shower tray, bathroom floor, toilet edge, the traditional system had an effectiveness of less than 10%, whereas pre-impregnated cloths succeed to eliminate about 90% of the bacteria present. As an example, on the floor we observed a microbial count reduction from >42 to 10 CFU/11 cm² with the new method (76% of colonies were destroyed), while with the traditional one we have a reduction from >42 to 28 CFU/11 cm² (33% of microbial colonies).

Moreover, the advantages of using this sanitization system are not limited to disinfecting surfaces and limiting cross-contamination but involve all activities related to the cleaning and disinfection operations, including the training and education of the operators and traceability of the operations.

Conclusions

The innovative disinfection and cleaning protocol used in the present study proved to be a highly valuable alternative to the traditional cleaning procedures in healthcare settings for the sanitizing process of all kinds of surfaces. All tools were specifically designed to improve disinfection efficiency and to reduce the problems associated with traditional methods, such as preventing cross-contamination events, limiting the physical efforts of operators, and avoiding incorrect practices. Our findings add support to the knowledge that an effective sanitization procedure is critical in minimizing microorganisms' transmission and cross-contamination.

Surface sampling within a pediatric ward-how multiple factors affect cleaning efficacy

BACKGROUND

The objectives of this study were to assess the number of organisms present on different surfaces within a clinical environment before and after cleaning took place, and to identify the impact of cleaning. The study involved extensive 2-week microbiological environmental monitoring of an entire ward before and after cleaning; the ward was located within a pediatric hematology-oncology ward comprised of a day unit and outpatient ward.

METHODS

Tryptone soya agar contact plates were used to take a total of 1,160 surface samples before and after cleaning from 55 predetermined sites. Samples were taken from representative surfaces throughout the ward representing a variety of materials, surface heights, functions, and distances from patients, as well as both high-touch and infrequently touched surfaces.

RESULTS

After surface cleaning was undertaken within the ward, there was a significant difference between the amount of colony-forming units (CFUs) recovered before and after cleaning (P < .0001). Cleaning produced an average CFU reduction of 68% throughout the ward environment. The corridor was the most contaminated area within the ward. There were differences in the CFUs among the various areas within the ward, which were cleaned with varying efficiency. The surface material, who interacted with the surface, levels of initial contamination, perceived risk, and perceived cleanability were all found to have a varying impact on the cleaning effectiveness.

CONCLUSIONS

To the authors' current knowledge, this is the only study to assess cleaning within a pediatric ward by taking samples directly before and after cleaning. The standard of cleaning undertaken within the ward is open for discussion, and these data highlight the need for an improved cleaning intervention and can provide insight into the multitude of factors that must be considered when designing an effective training protocol.

Molecular characterization of clinical and environmental carbapenem resistant Acinetobacter baumannii isolates in a hospital of the Eastern Region of Saudi Arabia

BACKGROUND

Environmental and clinical carbapenem-resistant Acinetobacter baumannii (CRAb) isolated in a hospital of the Eastern Region of Saudi Arabia were compared to assess the potential environmental contamination by this pathogen.

METHODS

Frequent-hand-touch surfaces of intensive care (ICU), medical (MW), and surgical (SW) units were randomly sampled for a month-long period, and the CRAb identified were compared to clinical isolates of the same period by PFGE and bla_OXA-51-like gene sequencing. Carbapenemase and ribosomal methylase genes, ISAba1 link to bla_OXA51-like or to bla_OXA-23, respectively were detected by PCR.

RESULTS

CRAb was identified from 35.5% of surfaces. All environmental and clinical isolates were multi- or extremely drug resistant. PFGE of all clinical (n=21) and selected environmental (n=30) isolates identified a singleton and four clusters, all of which included both clinical and environmental isolates. In the two largest clusters isolates carried bla_OXA-66, ISAba1-linked bla_OXA-23, and were from the ICU, MW and the male SW. Isolates of the female SW carried bla_OXA-69, ISAba1-linked bla_OXA-23 and bla_GES-11. A pair of clinical and environmental CRAb from the Male SW harboured bla_NDM-1 in addition to ISAba1-linked bla_OXA-94.

CONCLUSION

A worrying level of environmental contamination, often by CRAb belonging to international clones, was revealed, highlighting the importance of environmental hygiene.

How to carry out microbiological sampling of healthcare environment surfaces? A review of current evidence

There is increasing evidence that the hospital surface environment contributes to the spread of pathogens. However, evidence on how best to sample these surfaces is inconsistent and there is no guidance or legislation in place on how to do this. The aim of this review was to assess current literature on surface sampling methodologies, including the devices used, processing methods, and the environmental and biological factors that might influence results. Studies published prior to March 2019 were selected using relevant keywords from ScienceDirect, Web of Science, and PubMed. Abstracts were reviewed and all data-based studies in peer-reviewed journals in the English language were included. Microbiological air and water sampling in the hospital environment were not included. Although the numbers of cells or virions recovered from hospital surface environments were generally low, the majority of surfaces sampled were microbiologically contaminated. Of the organisms detected, multidrug-resistant organisms and clinically significant pathogens were frequently isolated and could, therefore, present a risk to vulnerable patients. Great variation was found between methods and the available data were incomplete and incomparable. Available literature on sampling methods demonstrated deficits with potential improvements for future research. Many of the studies included in the review were laboratory-based and not undertaken in the real hospital environment where sampling recoveries could be affected by the many variables present in a clinical environment. It was therefore difficult to draw overall conclusions; however, some recommendations for the design of routine protocols for surface sampling of healthcare environments can be made.

Pitfall benchmarking of cleaning costs in hospitals

Purpose

It is typical of public real estate benchmarking reports to show only highly aggregated benchmarks based on buildings’ floor areas. They hardly provide disaggregated benchmarks for usage clusters. The aim of this study is to show the caveats from highly aggregated benchmarking without consideration of cluster-specific characteristics.

Design/methodology/approach

Based on the parameters of the German facility management association 812 standards, cleaning costs and costs for the surfaces of seven hospitals have been collected and allocated to specific room clusters. Using these basic data, a calculation and simulation conducted with the aim of simulating facilities that are comparable in the sum of costs yet feature varying sub-clusters as cost drivers. In particular, during this simulation, area ratios were varied randomly and the average cleaning costs per cluster were held constant for all hospitals. Therefore, the costs per square meter in the clusters of all simulated hospitals are identical and the full costs only depend on the area ratios.

Findings

The simulation shows that highly aggregated cleaning costs lead to large spans, and thus, to misinterpretations in the field of action. In the case, the aggregate benchmark ranges from 40.6 to 66.5 EUR/m², although, for all hospitals the same costs per square meter had been used. Thus, the bias results only from varying the share of area across the clusters. This finding is caused by a well-known statistical problem: the Simpson’s paradoxon, which currently receives little attention in real estate benchmarking.

Practical implications

The results show, that the regular benchmarking with high aggregated data, often used in practice, cannot be recommended. The author consider using a detailed benchmarking as meaningful and purposeful. To be able to make a detailed benchmarking, it is essential to identify and collect the influencing factors. Only if all important factors, in this case, the clusters will be regarded in the benchmarking, a reasonable benchmarking and useful interpretation can be given. Using a simple benchmarking to get a rough overview is refused steadfastly.

Originality/value

The study highlights that a comparison with public benchmarking reports (operation costs) must be taken with great caution. The author has quantified the bias from the aggregated benchmarking and have shown, that the Simpson’s paradox fully explains the consequences.

What's on your keyboard? A systematic review of the contamination of peripheral computer devices in healthcare settings

OBJECTIVE

To determine the extent and type of microbial contamination of computer peripheral devices used in healthcare settings, evaluate the effectiveness of interventions to reduce contamination of these devices and establish the risk of patient and healthcare worker infection from contaminated devices.

DESIGN

Systematic review METHODS: We searched four online databases: MEDLINE, CINAHL, Embase and Scopus for articles reporting primary data collection on contamination of computer-related equipment (including keyboards, mice, laptops and tablets) and/or studies demonstrating the effectiveness of a disinfection technique. Pooling of contamination rates was conducted where possible, and narrative synthesis was used to describe the rates of device contamination, types of bacterial and viral contamination, effectiveness of interventions and any associations between device contamination and human infections.

RESULTS

Of the 4432 records identified, a total of 75 studies involving 2804 computer devices were included. Of these, 50 studies reported contamination of computer-related hardware, and 25 also measured the effects of a decontamination intervention. The overall proportion of contamination ranged from 24% to 100%. The most common microbial contaminants were skin commensals, but also included potential pathogens including methicillin-resistantStaphylococcus aureus, Clostridiumdifficile, vancomycin-resistantenterococci and Escherichia coli. Interventions demonstrating effective decontamination included wipes/pads using isopropyl alcohol, quaternary ammonium, chlorhexidine or dipotassium peroxodisulfate, ultraviolet light emitting devices, enhanced cleaning protocols and chlorine/bleach products. However, results were inconsistent, and there was insufficient data to demonstrate comparative effectiveness. We found little evidence on the link between device contamination and patient/healthcare worker colonisation or infection.

CONCLUSIONS

Computer keyboards and peripheral devices are frequently contaminated; however, our findings do not allow us to draw firm conclusions about their relative impact on the transmission of pathogens or nosocomial infection. Additional studies measuring the incidence of healthcare-acquired infections from computer hardware, the relative risk they pose to healthcare and evidence for effective and practical cleaning methods are needed.

Overall bioburden by total colony count does not predict the presence of pathogens with high clinical relevance in hospital and community environments

BACKGROUND

Healthcare-associated infections (HAIs) affect millions of patients, increasing morbidity and mortality. Pathogens of HAIs originate from both the patient's own flora and the environment, including multi-drug-resistant organisms.

AIMS

To determine the bioburden on different types of high-touch surfaces, and to identify cultures to species level and stratify strains into those of low and high clinical relevance.

DESIGN

Association between bioburden and presence of pathogens of high clinical relevance (PHCR) in a tertiary care centre and urban environment.

METHODS

The overall bioburden measured by total colony count (TCC) was assessed using tryptic soy agar contact plates and two selective agars to improve detection of PHCR. Isolates were routinely identified to species level using matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF). The definition of PHCR was based on listings outlined by the Centers for Disease Control and Prevention.

FINDINGS

In total, 1431 contact plates were processed from 477 surfaces: 153 from hospitals and 324 from publicly accessible institutions or devices. At least one PHCR was identified from cultures from 73 samples. TCC was found to be poorly correlated with the presence of PHCR.

CONCLUSION

TCC poorly predicted the presence of PHCR, rendering the results from environmental sampling difficult to interpret. MALDI-TOF enables the identification of large numbers of isolates from the environment at low cost. Further studies on environmental contamination should use MALDI-TOF to identify all pathogens grown.

Assessment health status of ICU medical equipment levels at Neyshabur hospitals using ICNA and ACC indices

This study was conducted to evaluate the health status of medical equipment's in Neyshabur hospital's intensive care units (ICU) before and after daily cleaning in order to compare the efficiency of the observational and microbial methods in evaluating hygienic conditions and cleaning of the environmental surfaces at the hospitals in Neyshabur. The study was performed in a ten-week period, twice a week before and after daily cleaning according to the ICNA observational method and the ACC microbial method were performed on the selected sites. (before and after daily cleaning in order to compare ICNA observational method and the ACC microbial method which performed on the selected sites). Result showed in total, 826 ICNA checklists were completed in this research for the 13 studied spots, 27.12% of the spots were contaminated before cleaning procedures, which dropped to 7.75% after cleaning. Data of the samples using the ACC index revealed that 74.82 were contaminated and 7.75% were clean. Bottle suction with 8.2% and Electroshock with 1% were the most and the least contaminated spots, respectively. As the results proved, the microorganism of Staphylococcus epidermises is the most grown organism in the intensive care unit. This study suggests that visual assessment is not enough to ensure quality of the process and it is necessary to document the level of cleanliness by quantitative methods. Also preparing the integrated instructions and guidelines of cleaning and disinfection and its continuous monitoring with standard methods would be effective in reducing the microbial contamination.

Improving daily patient room cleaning: an observational study using a human factors and systems engineering approach

Background

While playing a critical role in preventing healthcare-associated infections, patient room cleaning is often unsatisfactorily performed. To improve patient room cleaning, a human factors and systems engineering (HFSE) approach is needed to understand the complex cleaning process and associated work system factors.

Purpose

We conducted an observational study to assess the performance of environmental care (EVC) associates during daily patient room cleaning and identify work system factors influencing their performance.

Methods

This study was conducted in eight adult medicine inpatient units at a large urban academic medical center. An HFSE researcher shadowed 10 day-shift EVC associates performing daily patient room cleanings and used a semi-structured observation form to collect quantitative data (e.g., duration of room cleaning, orders for surface cleaning) and qualitative data (e.g., challenges to patient room cleaning). Descriptive statistics (e.g., median, interquartile range) were reported for cleaning performance, and bivariate and regression analyses were conducted to identify factors influencing cleaning performance. We also performed link analyses of the workflow of EVC associates and qualitative analyses of observer notes to identify challenges to daily patient room cleaning.

Results

We observed 89 patient room cleanings. Median duration of cleaning a room was 14 minutes, and median percentage of surfaces cleaned in a room was 63%. High-touch surfaces that were frequently missed during daily cleaning included the bedrails, telephone, patient and visitor chairs, and cabinet. Work system factors that could influence cleaning performance included the type of unit, the presence of the patient and family members in the room, cleaning patterns and orders of EVC associates, and interruptions EVC associates encountered while cleaning.

Conclusions

Daily patient room cleaning was influenced by a number of work system factors. To improve daily patient room cleaning, multifaceted interventions are needed to address these system-level factors.

Translating research to policy at the NCSE 2017 symposium "Microbiology of the Built Environment: Implications for Health and Design"

Here, we summarize a symposium entitled "Microbiology of the Built Environment: Implications for Health and Design" that was presented at the National Council for Science and the Environment (NCSE) 17th National Conference and Global Forum in January 2017. We covered topics including indoor microbial exposures and childhood asthma, the influence of hospital design on neonatal development, the role of the microbiome in our premise (i.e., building) plumbing systems, antibiotic resistance, and quantitative microbial risk assessment. This symposium engaged the broader scientific and policy communities in a discussion to increase awareness of this critical research area and translate findings to practice.

Surveillance of bacterial colonisation on contact surfaces in different medical wards

This study was conducted to determine the bacterial colonization of some bacterial groups, including extended-spectrum β-lactamase (ESBLs) producers and methicillin-resistant Staphylococcus aureus (MRSA), on surfaces of the equipment and instruments in patient rooms and other workspaces in three different medical wards. The number of microorganisms on swabs was determined with the colony count method on selective microbiological mediums. The aerobic mesophylic microorganisms were found in 73.5 % out of 102 samples, with the average and maximum values of 2.6 × 102 and 4.6 × 103 colony forming units (CFU) 100 cm-2, respectively. Members of the family Enterobacteriaceae, coagulase positive staphylococci, coagulase-negative staphylococci, and enterococci were detected in 23.4, 31.4, 53.2, and 2.9 % of samples, respectively. The differences in bacterial counts on the surfaces of the psychiatric, oncology, and paediatric wards were statistically significant (P<0.001). About 40 % out of 19 isolates from the family Enterobacteriaceae showed multiple resistance to three or more different groups of tested antibiotics, while ESBL was confirmed for only one strain. Staphylococci isolates were mostly resistant to penicillin. MRSA was confirmed in 5.2 % of the tested S. aureus isolates. Greater attention should be paid to cleaning and the appropriate choice of disinfectants, especially in the psychiatric ward. Employees should be informed about the prevention of the spreading of nosocomial infections. Routine application of rapid methods for hygiene control of surfaces is highly recommended.

In situ antimicrobial behavior of materials with copper-based additives in a hospital environment

Copper and its alloys are effective antimicrobial surface materials in the laboratory and in clinical trials. Copper has been used in the healthcare setting to reduce environmental contamination, and thus prevent healthcare-associated infections, complementing traditional protocols. The addition of copper nanoparticles to polymer/plastic matrices can also produce antimicrobial materials, as confirmed under laboratory conditions. However, there is a lack of studies validating the antimicrobial effects of these nanocomposite materials in clinical trials. To satisfy this issue, plastic waiting room chairs with embedded metal copper nanoparticles, and metal hospital IV pools coated with an organic paint with nanostructured zeolite/copper particles were produced and tested in a hospital environment. These prototypes were sampled once weekly for 10 weeks and the viable microorganisms were analysed and compared with the copper-free materials. In the waiting rooms, chairs with copper reduced by around 73% the total viable microorganisms present, showing activity regardless of the microorganism tested. Although there were only low levels of microorganisms in the IV pools installed in operating rooms because of rigorous hygiene protocols, samples with copper presented lower total viable microorganisms than unfilled materials. Some results did not have statistical significance because of the low load of microorganisms; however, during at least three weeks the IV pools with copper had reduced levels of microorganisms by a statistically significant 50%. These findings show for the first time the feasibility of utilizing the antimicrobial property of copper by adding nanosized fillers to other materials in a hospital environment.

EVALUATION OF THREE SURFACE FRICTION TECHNIQUES FOR THE REMOVAL OF ORGANIC MATTER

ABSTRACT The objective of this study was to assess the effectiveness of three surface friction techniques for the removal of organic material. A quantitative, descriptive and exploratory study was developed to evaluate the presence or not of organic material before and after the cleaning and disinfection process of surfaces of bedside tables of patients hospitalized at an Intensive Care Unit. Three friction techniques were executed in the one-way, two-way and centrifugal sense, individually, three times on each table, during alternate weeks. For each patient unit and friction technique, a single table and three sides of cloth were used, moistened with 70% (w/v) alcohol. The organic matter was detected through the presence of adenosine triphosphate by bioluminescence, using 3M(tm) Clean-Trace(tm) ATP Systems. For each technique, 13 samples were collected before and 13 after the cleaning/disinfection process, totaling 78 samples of adenosine triphosphate by bioluminescence. No statistically significant difference was found among the removal techniques of organic matter. This study demonstrated that none of the three surface friction methods was better than the other to remove organic matter. Nevertheless, further research is needed in which other cleaning/disinfection indicators and surfaces are considered.

Cleaning Hospital Room Surfaces to Prevent Health Care-Associated Infections: A Technical Brief

The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Keyboard cleanliness: a controlled study of the residual effect of chlorhexidine gluconate

A controlled trial of once daily cleaning of computer keyboards in an intensive care unit was performed comparing 2% chlorhexidine gluconate-70% isopropyl alcohol (CHG) and a chlorine dioxide-based product used as a standard in our hospital. A study before and after the introduction of once daily keyboard cleaning with CHG in the wider hospital was also completed. Cleaning with CHG showed a sustained and significant reduction in bacterial colony forming units compared with the chlorine dioxide-based product, demonstrating its unique advantage of maintaining continuous keyboard cleanliness over time.

Determination of ATP-activity as a useful tool for monitoring microbial load in aqueous humidifier samples

Air humidifier water tanks are potential sources of microbial contaminants. Aerosolization of these contaminants is associated with the development of airway and lung diseases; therefore, implementation of preventive strategies including monitoring of the microbial contamination is recommended. So far, culture-based methods that include measuring colony forming units (CFU) are widely used to monitor microbial load. However, these methods are time consuming and have considerable drawbacks. As a result, alternative methods are needed which provide not only clear and accurate results concerning microbial load in water samples, but are also rapid and easy to use in the field. This paper reports on a rapid test for ATP quantification as an alternative method for microbial monitoring, including its implementation, validation and application in the field. For this purpose, 186 water samples were characterized with different methods, which included ATP analysis, culture-based methods, endotoxin activity (common and rapid test), pyrogenic activity and number of particles. Half of the samples was measured directly in the field and the other half one day later in the laboratory. The results of both tests are highly correlated. Furthermore, to check how representative the result from one sample of a water source is, a second sample of the same water tank were collected and measured. Bioluminescence results of the undiluted samples covered a range between 20 and 25,000 relative light units (RLU) and correlated with the results obtained using the other methods. The highest correlation was found between bioluminescence and endotoxin activity (rs=0.79) as well as pyrogenic activity (rs=0.75). Overall, the results of this study indicate that ATP measurement using bioluminescence is a suitable tool to obtain rapid, reproducible and sensitive information on the microbial load of water samples, and is suitable to use in the field. However, to use ATP measurement as an indicator of water quality, criteria of assessment has to be discussed.

Routine monitoring of adenovirus and norovirus within the health care environment

This study investigated the presence of adenovirus and norovirus on ward surfaces using real-time polymerase chain reaction (PCR) to assist in the development of evidence-based infection control policy. Screening was carried out weekly for 6 months in the common areas of 2 pediatric wards. Additionally, a one-off screening was undertaken for adenovirus and norovirus on a day unit and for adenovirus only in patient cubicles while occupied. Over the 6-month screening of common areas, 2.4% of samples were positive for adenovirus or norovirus. In rooms occupied with adenovirus-infected children, all cubicle screening sites and almost all swabs were contaminated with adenovirus. In the day unit, 13% of samples were positive. Cleaning and environmental interaction strategies must therefore be designed to control nosocomial transmission of viruses outside of outbreak scenarios.

Evaluating a new paradigm for comparing surface disinfection in clinical practice

BACKGROUND

Despite an increasing understanding of the importance of near-patient surfaces in the transmission of healthcare-associated pathogens, there remains a need to define the relative clinical effectiveness of disinfection interventions.

DESIGN

A serial 2-phase evaluation of the clinical effectiveness of 2 surface disinfectants.

SETTING

A general acute care hospital.

METHODS

A unique system for quantifying bioburden reduction while monitoring the possible impact of differences in cleaning thoroughness was used to compare the clinical effectiveness of a traditional quaternary ammonium compound (QAC) and a novel peracetic acid/hydrogen peroxide disinfectant (ND) as part of terminal room cleaning.

RESULTS

As a result of QAC cleaning, 93 (40%) of 237 cleaned surfaces confirmed by fluorescent marker (DAZO) removal were found to have complete removal of aerobic bioburden. During the ND phase of the study, bioburden was removed from 211 (77%) of 274 cleaned surfaces. Because there was no difference in the thoroughness of cleaning with either disinfectant (65.3% and 66.4%), the significant ([Formula: see text]) difference in bioburden reduction can be attributed to better cleaning efficacy with the ND.

CONCLUSIONS

In the context of the study design, the ND was 1.93 times more effective in removing bacterial burden than the QAC ([Formula: see text]). Furthermore, the study design represents a new research paradigm in which 2 interventions can be compared by concomitantly and objectively analyzing both the product and process variables in a manner that can be used to define the relative effectiveness of all disinfection cleaning interventions.

How clean is clean--is a new microbiology standard required?

The role of environment in the spread of nosocomial infection has been acknowledged. One way to control the spread of infection is to control and monitor patient environments to prevent transmission. Studies applying the suggested aerobic colony count standards to monitor environmental contamination were undertaken over an 18-month period at both a London pediatric hospital and in adult intensive care units. The resulting data demonstrate that a large proportion of sites screened for bacterial contamination would fail if using the criteria suggested by previous authors-particularly those sites closest to patients-suggesting a new standard might be required.

Relationship between nasal colonization and ventilator-associated pneumonia and the role of the environment in transmission of Staphylococcus aureus in intensive care units

BACKGROUND

This study assessed the relationship between nasal colonization and ventilator-associated pneumonia (VAP) by Staphylococcus aureus, as well the role of the environment in the transmission of this organism.

METHODS

We performed a cohort study of patients with VAP caused by methicillin-resistant S aureus (MRSA) or methicillin-sensitive S aureus during 2 years in an adult intensive care unit (ICU). All patients had nasal swab specimens obtained at admission and during the ICU stay. Clinical samples also were collected for analysis, as were samples from the hands of health care professionals and the environment, and were typed using pulsed-field gel electrophoresis.

RESULTS

S aureus VAP represented 12.5% of the cases, and statistical analysis identified colonization as a risk factor for the development of this infection. MRSA was isolated from the environment and hands, indicating the existence of a secondary reservoir. Molecular typing revealed a polyclonal profile; however, clone J was the most frequent (45.5%) among isolates of MRSA tested, with a greater profile of resistance than the other isolates. There was strong evidence suggesting transmission of MRSA to patients from the environment.

CONCLUSION

Nasal colonization for S aureus is a risk factor for development of VAP.

Effectiveness of visual inspection compared with non-microbiologic methods to determine the thoroughness of post-discharge cleaning

Background

Published data to date have provided a limited comparison between non-microbiologic methods—particularly visual inspection—and a microbiologic comparator to evaluate the effectiveness of environmental cleaning of patient rooms. We sought to compare the accuracy of visual inspection with other non-microbiologic methods of assessing the effectiveness of post-discharge cleaning (PDC).

Methods

Prospective evaluation to determine the effectiveness of PDC in comparison to a microbiologic comparator. Using a highly standardized methodology examining 15 high-touch surfaces, the effectiveness of PDC was evaluated by visual inspection, the removal of fluorescent marker (FM) placed prior to room occupancy, quantification of adenosine triphosphate (ATP) levels, and culture for aerobic colony counts (ACC).

Results

Twenty rooms including 293 surfaces were sampled in the study, including 290 surfaces sampled by all four methods. ACC demonstrated 72% of surfaces to be microbiologically clean. Visual inspection, FM, ATP demonstrated 57%, 49%, and 66% of surfaces to be clean. Using ACC as a microbiologic comparator, the sensitivity of visual inspection, FM, and ATP to detect a clean surface were 60%, 51%, and 70%, respectively; the specificity of visual inspection, FM, and ATP were 52%, 56%, and 44%.

Conclusions

In assessing the effectiveness of PDC, there was poor correlation between the two most frequently studied commercial methods and a microbiologic comparator. Visual inspection performed at least as well as commercial methods, directly addresses patient perception of cleanliness, and is economical to implement.

Methods for assessing the adequacy of practice and improving room disinfection

The value of objectively monitoring and improving environmental cleaning in health care settings is becoming increasingly recognized as an important component of interventions to mitigate the transmission of health care-associated pathogens. Whereas the 2010 Centers for Disease Control and Prevention tool kit "Options for Evaluating Environmental Cleaning" provides detailed guidance related to implementing such programs, there is a need to clearly understand the value and limitations of various environmental cleaning monitoring approaches to ensure the favorable impact of such activities.

Randomized double-blind crossover trial of ultraviolet light-sanitized keyboards in a pediatric hospital

The effectiveness of ultraviolet light disinfection of keyboards was assessed in the intensive care unit and emergency department of a pediatric hospital. Ultraviolet light disinfection was 67% effective (95% confidence interval, 46%-87%) in eliminating bacterial contamination as measured by quantitative bacterial culture.

Condition of cleanliness of surfaces close to patients in an intensive care unit

Surface cleaning is a well-known control procedure against the dissemination of microorganisms in the hospital environment. This prospective study, carried out in an intensive care unit over the course of 14 days, describes the cleaning/disinfection conditions of four surfaces near patients. In total, 100 assessments of the surfaces were carried out after they were cleaned. Three methods were used to evaluate cleanliness: a visual inspection, an adenosine triphosphate (ATP) bioluminescence assay and testing for the presence of Staphylococcus aureus and meticillin-resistant Staphylococcus aureus/MRSA. Respectively, 20%, 80% and 16% of the assessments by the visual method, ATP and the presence of Staphylococcus aureus/MRSA failed. There were statistically significant differences (p<0.05) between the rates of failure of the cleaning using the ATP method, compared to the visual and microbiological methods. The visual inspection was not a reliable measure to evaluate surface cleanliness. The results demonstrated that the adopted cleaning routine should be reconsidered.

Methicillin-resistant Staphylococcus aureus on surfaces of an Intensive Care Unit

OBJECTIVE: To evaluate the presence of methicillin-resistant Staphylococcus aureus (MRSA) in areas close to patients in a General Intensive Care Unit. METHODS: This is a cross-sectional study, in which microbiological samples were collected from five surfaces (left / right bed siderails, bed crank, table, buttons on the infusion pump, and cotton gowns) from each of ten patient rooms, totaling 63 samples. To collect samples, the Petri FilmTM Staph Express Count System 3M TM was used to screen for methicillin resistance, with the Mueller-Hinton agar supplemented with 4% sodium chloride and 6 µg / ml of oxacillin. Descriptive analysis was conducted to determine the frequency (n) and percentage (%) of contamination of environmental surfaces. RESULTS: Of 48 samples positive for Staphylococcus aureus, 29 (60.4%) were resistant to methicillin. The incidence on the siderails and bed cranks, table, buttons on the infusion pumps and aprons were, respectively, 55.5%, 57.1%, 57.1%, 60.0% and 75.0%. CONCLUSION: The results suggest that the surfaces around the patient constitute a major threat, as they represent secondary reservoirs of MRSA.