Impact of Adenosine Triphosphate Detection and Feedback on Hospital Room Cleaning Author(s): Philip W. Smith, MD; Elizabeth Beam, MSN, RN; Harlan Sayles, MS; Mark E. Rupp, MD; R. Jennifer Cavalieri, RN; Shawn Gibbs, PhD; Angela Hewlett, MD, MS Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 5 (May 2014), pp. 564-569 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America
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infection control and hospital epidemiology
may 2014, vol. 35, no. 5
original article
Impact of Adenosine Triphosphate Detection and Feedback on Hospital Room Cleaning Philip W. Smith, MD;1,2 Elizabeth Beam, MSN, RN;3 Harlan Sayles, MS;2 Mark E. Rupp, MD;1 R. Jennifer Cavalieri, RN;1 Shawn Gibbs, PhD;2 Angela Hewlett, MD, MS1,2
objective. To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy. design. setting.
Nonrandomized controlled trial conducted over 20 months. Three hospitals of varying size.
participants.
EVS workers, randomly selected on the basis of convenience sample of rooms.
interventions. Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions. results.
Cleaning efficacy improved significantly with each intervention (P ! .01) and decreased during the washout period.
conclusions. The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment. Infect Control Hosp Epidemiol 2014;35(5):564-569
Increasing attention has focused on the contribution of the hospital environment to acquisition of healthcare-associated infection (HAI).1-3 Cleaning has an impact on both environmental contamination and clinical infections; however, environmental contamination may not be eradicated by routine cleaning because of a lack of thoroughness.4,5 Although appropriate cleaning should reduce the risk of acquisition of HAIs, methods for monitoring the cleanliness of the hospital environment are not well established. Visual inspection of a surface is inadequate as a measure of cleanliness. Other techniques for assessing cleanliness include performing quantitative cultures of environmental surfaces, the use of fluorescent dye, and adenosine triphosphate (ATP) detection devices. Comparisons have shown inconsistent correlation between the methods.6-8 In this study, we undertook a prospective, layered program of educational interventions involving feedback using the ATP detection device and monitored subsequent trends in environmental cleanliness.
methods Our goal was to study the effect of educational and behavioral interventions on hospital room cleaning by introducing 4 layered educational interventions at 3-month time intervals.
The impact of the interventions was measured by monitoring room cleanliness after standard terminal cleaning by environmental services (EVS) personnel using the ATP bioluminescence assay. A composite monthly cleaning score was determined via ATP testing of multiple high-touch hospital room sites. This monthly composite score was the percentage, divided by 10 to put it on a 0–10 scale, of “clean” ATP results for each of the 16 room sites (Table 1) in each of the 2 rooms tested per unit per week. The monthly composite score was calculated per unit and for all units combined. Five clinical units at 3 Nebraska hospitals of differing sizes were chosen for the intervention. Hospital A was a 635-bed acute care, academic, tertiary referral hospital in Omaha, Nebraska, for the University of Nebraska Medical Center (UNMC). Study units included a 40-bed general medical/ surgical unit (unit A1), a 32-bed telemetry unit (unit A2), and a 7-bed burn unit that has both burn and nonburn patients (unit A3). Hospital B is a 184-bed acute care hospital in western Nebraska; the study unit was an 18-bed intensive care unit (ICU). Hospital C is a 47-bed acute care hospital in northeast Nebraska; the study unit was a 9-bed ICU. Each hospital used their routine cleaning protocols during the study. Two control units at hospital A were chosen for the
Affiliations: 1. College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; 2. College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska; 3. College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska. Received October 10, 2013; accepted December 31, 2013; electronically published March 19, 2014. 䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3505-0014$15.00. DOI: 10.1086/675839
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impact of atp detection and feedback on hospital room cleaning
table 1. Room Surface Size versus Cleanliness Surface Bathroom inner door handle Toilet seat Main light switch Nurse call light Patient phone Room chair arms Mattress Top surface/bedside table Bedrail Bedrail inside control panel Sink light switch External door handle High/low control lever on bedside table Toilet flusher Sink faucet handle Soap dispenser
Surface area, cm2
Clean,a %
567 351 203 136 126 105 100 100 100 100 95 85 82 78 60 56
83.5 83.7 86.7 74.4 76.1 53.1 93.3 79.3 72.7 50.8 87.5 88.9 61.5 73.1 61.0 82.8
note. ATP, adenosine triphosphate. a Defined as ATP less than 250 relative light units.
collection of infection surveillance data only, a 36-bed medical/surgical unit (A4) and a 49-bed cardiac unit (A5). These 2 units did not receive ATP assays after cleaning or education of EVS personnel. The study was approved by the institutional review boards (IRBs) at UNMC and hospital B; hospital C subcontracted with the UNMC IRB. All 3 hospitals are members of the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). ATP readings were obtained using the 3M Clean Trace ATP system, an ATP bioluminescence assay (3M Clean-Trace Surface ATP System; 3M). A sterile polystyrene swab was rubbed over a high-touch area for 30 seconds, placed in a plastic
tube and shaken for 30 seconds, and then placed in the portable handheld luminometer that provides a digital readout of the light generated by the luciferase reaction, expressed digitally as relative light units (RLUs). We selected the most widely used threshold for clean surfaces as readings below 250 RLU per surface.6,7 RLUs were not standardized to a per unit area measurement but were left as raw measurements regardless of the size of the area being tested to simulate likely real life use conditions. This study focused on trends in the percentage of clean surfaces rather than the absolute values of the ATP readings. Data Collection The infection preventionists (IPs) at hospitals B and C served as study coordinators, while a healthcare epidemiology research nurse served in this role at hospital A. At each hospital, the study coordinator was responsible for implementing educational activities as well as overseeing the ATP and HAI data collection. A physician infection control specialist provided on-site training at the initiation of the study and throughout the study period. The IP position at hospital B was filled by 3 individuals during the study period, but there were no interruptions in data collection. A true convenience sample of 2 rooms per week in each study unit ready for terminal cleaning were selected on the basis of availability. Study personnel were notified by EVS that a patient was discharged from the hospital, and the room was cleaned. EVS workers and their managers were unaware of which rooms were selected for testing. Information regarding which room was cleaned and which EVS personnel did the cleaning were collected confidentially and pooled at the unit level to protect the identity of the cleaners. Terminal cleaning was performed in a standard fashion,
table 2. Schedule of Educational Intervention Activities Study period 1
2
3
4 5 note.
565
Description of intervention ATP results feedback to EVS. EVS workers were given feedback on performance by a pooled score consisting of composite unit score (from 0 to 10) of room surfaces rated clean. Graphic displays were used to show trends in the composite scores over time, and monthly newsletters highlighted unit-specific composite monthly scores. A study introduction video was shared with the EVS workers at an initial meeting. Study engagement materials (eg, lunch bags, lanyards, buttons) were shared throughout the study. Hands-on use of ATP devices by EVS. EVS workers were given the opportunity to use the ATP device in a hospital room, under the direction of the site study nurse, including testing 3 room surfaces, cleaning, and then observing the improvement in ATP score after cleaning. Additional educational materials included a laminated pocket-size cleaning order and hightouch surfaces list in both English and Spanish. Education of EVS through an electronic game. The cleaning success of room surfaces was shared with EVS using the “Clean Sweep” electronic game. The user selected 3 high-touch surfaces for first, second, and third cleanest and least clean surfaces from a drop-down menu, then submitted the data to get feedback on their selection (see Figure 2). Additional rewards for performance. All EVS workers from each unit that improved were given a pizza luncheon upon release of the previous month’s scores. Washout period; no interventions
ATP, adenosine triphosphate; EVS, environmental services.
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may 2014, vol. 35, no. 5
figure 1. Screen shot of “Clean Sweep” electronic game for environmental services (EVS) workers. Developed by Stephen Smith, Instructional Technologist, University of Nebraska Medical Center College of Nursing.
involving collecting trash and linen, high dusting, wet dusting, wiping of surfaces with disinfectant (a quaternary ammonium compound), floor cleaning, bathroom cleaning, and room inspection. The room was then tested with the ATP device, generally 30–60 minutes after cleaning. Sampling consisted of ATP readings on 16 high-touch surfaces per room, as listed in Table 1.6,9-12 For each sample, the entire surface area of was swabbed except for large surfaces, like the mattress and bedside table, where a 10 # 10-cm template was used (Table 1). Study periods were limited to those in which data from all 5 sites were collected. In addition to cleaning score measurements over time, trends in HAIs were observed. Infections were detected by routine surveillance procedures at the respective hospitals. Central line–associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were observed by standard active surveillance, whereas Clostridium difficile infection, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococcus infections were observed by laboratory-based surveillance. Standard NHSN definitions for HAIs were used.13 HAIs were calculated per 1,000 patient days. Our study was not designed to analyze
the significance of change in HAI rates with cleanliness but reported the HAI rates for completeness. Educational Interventions A nurse educator from the UNMC College of Nursing worked with EVS and infection control to develop appropriate interventions. Educational interventions were introduced to EVS by site IPs for 4 consecutive 3-month periods (Table 2; Figure 1). The interventions were layered (eg, each successive intervention was added to the previous interventions. ATP data collection began April 1, 2011, and ended December 31, 3012. The study included a 6-month baseline period before implementation of the interventions and a 3-month washout period after the interventions were stopped. Analysis and Statistical Methods The effects of the interventions and their removal during washout were estimated using a generalized linear mixed model with a 250 RLU pass/fail cutoff as the outcome. The model estimated the likelihood of surface cleanliness across the different periods of the study (baseline, intervention pe-
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impact of atp detection and feedback on hospital room cleaning
567
figure 2. Composite cleanliness scores during the study for each unit and overall score.
riods 1–4, and washout) while also modeling random effects for study site, observation (defined as the set of surfaces measured within a single room at a single point in time), and the surfaces themselves. Pairs of least-squares means were used to compare changes in the likelihood of surfaces being clean from one study period to the next. A similar model was used to analyze the likelihood of the item being clean versus the item’s surface area, again including random effects for surface type, observation, and site. A Spearman correlation between the surface area and the percentage clean was also used to assess a possible association. HAI rates were analyzed over time and between case and control groups using a Poisson regression model.
results The surface areas of the items ranged from 567 cm2 for the bathroom inner door handle to 56 cm2 for the soap dispenser. The site cleanliness ratings ranged from 93.3% for the mattress to 50.8% for the bedrail inside control panel. A model for whether a surface was clean by surface area (Table 1) did not reveal a significant association between site surface area and cleanliness (P p .52). The Spearman correlation between the surface area and the percentage clean demonstrated similar results (P p .49). The change in the cleanliness index (composite score on a 0–10 scale) of room surfaces per month that were above the “clean” threshold) is shown graphically in Figure 2. This reveals general improvement in scores with successive interventions and a trend toward decreased scores during the washout period. This figure displays trends for individual
units as well as an overall score for the 5 study units combined. Table 3 shows the actual numbers and percentages of surfaces that were clean using the 250 RLU cutoff for each intervention period. The likelihood of cleanliness increased throughout the 4 intervention periods before decreasing somewhat during the washout period. Comparison of least squares means from one study period to the next showed that each additional intervention resulted in a statistically significant increase in surface cleanliness (Table 3); however, our study was not designed to quantitatively compare the effects of the various interventions. Analysis of total HAIs that were measured in study and control units before, during, and after the intervention periods did not reveal any significant change in HAI rates during the study periods or any differences between study and control unit rates.
discussion It is recommended that infection control and EVS develop a program to assess terminal hospital room cleaning efficacy and use the results to provide feedback to improve room cleaning.1 ATP detection devices have the advantages of convenience and providing rapid results for prompt feedback to hospital cleaning personnel. Although an alternative method such as fluorescent dye shares some of these same advantages and uses, it has an element of subjectivity that is avoided with the use of ATP.9,14 The importance of EVS education is underscored by the poor baseline hospital room high-touch surface cleaning results, with approximately half of tested surfaces failing the
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infection control and hospital epidemiology
may 2014, vol. 35, no. 5
table 3. Percentage of Clean Surfaces for Each Study Period and Comparisons between Study Periods Study period Baseline Intervention Intervention Intervention Intervention Washout Total
1 2 3 4
Total sites tested
Clean sites, %a
Adjacent periods comparison
P
4,030 2,031 1,879 1,865 1,893 1,647 13,345
44.0 55.0 66.8 75.6 86.5 82.8 61.3
... Baseline vs intervention 1 Intervention 1 vs intervention 2 Intervention 2 vs intervention 3 Intervention 3 vs intervention 4 Intervention 4 vs washout
!.001 !.001 !.002 !.001
.064
note. ATP, adenosine triphosphate. a Defined as ATP less than 250 relative light units.
after-cleaning assessment.1,9 Our baseline composite percentage of surfaces after cleaning that scored as “clean” (less than 250 RLU) was in that range (46%) but improved with each intervention to 79% in the final period (Table 3). It decreased to 76% in the 3-month washout period when all interventions were withdrawn. Each intervention resulted in a statistically significant improvement in performance, but we were unable to determine whether a particular intervention was superior to other interventions. In spite of the differences in hospital size and EVS programs, all units demonstrated improvement during the study. The lack of a correlation between surface area and cleaning score may be confounded by site complexity. The cleanest surface was the mattress, which is flat and easy to clean, whereas the site with the lowest cleanliness rating, the bedrail control panel, is a complex surface; however, a formal analysis of site complexity and cleanliness was not done. Although it is agreed that improvement in environmental cleaning is likely to decrease HAIs, standard surveillance did not reveal a significant change in HAI rates during the study. However, the primary purpose of our study was to evaluate the feasibility and effectiveness of the environmental ATP assay to measure trends in hospital rooms after cleaning with time. This portable and rapid assay can be used to test hightouch areas in hospital patient rooms after cleaning and observe trends with time to provide feedback and improve cleaning performance. It remains to be seen what effect implementation of ATP monitoring might have on HAI rates, especially if the monitoring were conducted facility-wide or applied to daily cleaning, rather than to terminal only. There are insufficient data on specific educational interventions for maximizing hospital room cleaning efficacy.15 A variety of methods have been recommended (eg, didactic sessions, cleaning checklists, cleaning demonstrations, and direct observation of the EVS worker), and feedback is an important part of the educational process.1,14-18 We introduced multiple layered educational interventions and noted an improvement in composite cleaning scores with each subsequent intervention. The educational interventions were designed to provide feedback; emphasize the importance of environmen-
tal cleaning, especially room high touch areas; and reward cleaning performance. Educational methods in this study hinged on adult learning theory, including the importance of self-direction, experiential learning, learning readiness, and the immediate application of new knowledge to current problems. Cleanliness in hospitals has been shown to improve with education and training of cleaning personnel.19 Guerrero et al20 demonstrated the importance of active interventions and direct interaction in improving hospital room cleaning by EVS. Adding a gaming element to competency training can be more engaging and helps to educate learners with different levels of learning ability.21 There was likely less value in obtaining the correct answers than in the consistent redirection of attention to cleaning of neglected high-touch surfaces. Limitations of this study include dependence of the ATP score on the manufacturer device22 and variable correlation with other methods that measure hospital environmental cleanliness.6,7 Use of the same device to measure the same room surfaces over time eliminates some concerns related to monitoring trends. Second, although all interventions demonstrated significant improvement in cleanliness scores, the study was not designed to compare the relative potency of the various interventions. The washout period did suggest that removal of the ATP program would lead to a decrease in cleaning efficacy, but the washout period was only 3 months. Third, use of the ATP device or the electronic educational game may not be financially feasible for smaller hospitals. Our study was not designed to correlate changes in HAIs with cleanliness efficacy. Finally, our educational feedback program was only used for terminal cleaning. Nevertheless, the ATP detection device can be used to provide timely feedback to EVS workers on the effectiveness of hospital environmental cleaning. Feedback of ATP results to EVS workers combined with various layered educational interventions resulted in significantly better ATP scores. Future studies should address the comparative efficacy of various educational interventions, the durability of feedback programs, the number of surfaces needed for representative sampling, and the cost effectiveness of the ATP detection method.
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impact of atp detection and feedback on hospital room cleaning
acknowledgments Financial support. The US Army Medical Research and Materiel Command and the Telemedicine and Advanced Technology Research Center at Fort Detrick, Maryland, provided funding for this study (W81XWH-10-1-0703). Potential conflicts of interest. M.E.R. reports that he serves on an advisory board for 3M and has a research contract from 3M awarded to University of Nebraska Medical Center. All other authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Address correspondence to Philip W. Smith, MD, College of Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198 ([email protected]).
11.
12.
13.
14.
references 1. Guh A, Carling P; Environmental Evaluation Workgroup. Options for evaluating environmental cleaning. http://www.cdc .gov/hai/toolkits/evaluating-environmental-cleaning.html. Updated 2010. Accessed October 1, 2013. 2. Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control 2013;41:S6–S11. 3. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006;166: 1945–1951. 4. Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol 2008;29:1–7. 5. Boyce JM, Havill NL, Lipka A, Havill H, Rizvani R. Variations in hospital daily cleaning practices. Infect Control Hosp Epidemiol 2010;31:99–101. 6. Boyce JM, Havill NL, Havill HL, Mangione E, Dumigan DG, Moore BA. Comparison of fluorescent marker systems with 2 quantitative methods of assessing terminal cleaning practices. Infect Control Hosp Epidemiol 2011;32:1187–1193. 7. Smith P, Sayles H, Hewlett AL, Cavalieri R, Gibbs S, Rupp M. A study of three methods for assessment of hospital environmental cleaning. Healthcare Infect 2013;18:80–85. 8. Sherlock O, O’Connell N, Creamer E, Humphreys H. Is it really clean? an evaluation of the efficacy of four methods for determining hospital cleanliness. J Hosp Infect 2009;72:140–146. 9. Carling PC, Parry MM, Rupp ME, et al. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol 2008;29:1035–1041. 10. Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun
15.
16.
17.
18.
19.
20.
21. 22.
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O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 2009;30:678–684. Smith PW, Gibbs S, Sayles H, Hewlett A, Rupp ME, Iwen PC. Observations on hospital room contamination testing. Healthcare Infection 2013;18:10–13. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850–853. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309–332. 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;38:387–392. Boyce JM, Havill NL, Dumigan DG, Golbiewski M, Balogun O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices using an ATP bioluminescence assay. Paper presented at: Society for Healthcare Epidemiology of America Annual Scientific Meeting; April 5–8, 2008; Orlando, Florida (Poster 276). Matlow AG, Wray R, Richardson SE. Attitudes and beliefs, not just knowledge, influence the effectiveness of environmental cleaning by environmental service workers. Am J Infect Control 2012;40:260–262. Rebmann T, Aureden K; Association for Professionals in Infection Control and Epidemiology. Preventing methicillin-resistant Staphylococcus aureus transmission in long-term care facilities: an executive summary of the APIC Elimination Guide. Am J Infect Control 2011;39:235–238. Havill NL. Best practices in disinfection of noncritical surfaces in the health care setting: creating a bundle for success. Am J Infect Control 2013;41:S26–S30. Aziz A. Can education and training for domestic staff increase awareness of infection control practices and improve cleanliness within hospitals? J Infect Preven 2009;10:171–177. Guerrero DM, Carling PC, Jury LA, Ponnada S, Nerandzic MM, Donskey CJ. Beyond the Hawthorne effect: reduction of Clostridium difficile environmental contamination through active intervention to improve cleaning practices. Infect Control Hosp Epidemiol 2013;34:524–526. Pauli P. Using games to demonstrate competency. J Nurses Staff Dev 2005;21:272–276. Whiteley GS, Derry C, Glasbey T. Reliability testing for portable adenosine triphosphate bioluminometers. Infect Control Hosp Epidemiol 2013;34:538–540.
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. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].
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infection control and hospital epidemiology
may 2014, vol. 35, no. 5
original article
Impact of Adenosine Triphosphate Detection and Feedback on Hospital Room Cleaning Philip W. Smith, MD;1,2 Elizabeth Beam, MSN, RN;3 Harlan Sayles, MS;2 Mark E. Rupp, MD;1 R. Jennifer Cavalieri, RN;1 Shawn Gibbs, PhD;2 Angela Hewlett, MD, MS1,2
objective. To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy. design. setting.
Nonrandomized controlled trial conducted over 20 months. Three hospitals of varying size.
participants.
EVS workers, randomly selected on the basis of convenience sample of rooms.
interventions. Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions. results.
Cleaning efficacy improved significantly with each intervention (P ! .01) and decreased during the washout period.
conclusions. The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment. Infect Control Hosp Epidemiol 2014;35(5):564-569
Increasing attention has focused on the contribution of the hospital environment to acquisition of healthcare-associated infection (HAI).1-3 Cleaning has an impact on both environmental contamination and clinical infections; however, environmental contamination may not be eradicated by routine cleaning because of a lack of thoroughness.4,5 Although appropriate cleaning should reduce the risk of acquisition of HAIs, methods for monitoring the cleanliness of the hospital environment are not well established. Visual inspection of a surface is inadequate as a measure of cleanliness. Other techniques for assessing cleanliness include performing quantitative cultures of environmental surfaces, the use of fluorescent dye, and adenosine triphosphate (ATP) detection devices. Comparisons have shown inconsistent correlation between the methods.6-8 In this study, we undertook a prospective, layered program of educational interventions involving feedback using the ATP detection device and monitored subsequent trends in environmental cleanliness.
methods Our goal was to study the effect of educational and behavioral interventions on hospital room cleaning by introducing 4 layered educational interventions at 3-month time intervals.
The impact of the interventions was measured by monitoring room cleanliness after standard terminal cleaning by environmental services (EVS) personnel using the ATP bioluminescence assay. A composite monthly cleaning score was determined via ATP testing of multiple high-touch hospital room sites. This monthly composite score was the percentage, divided by 10 to put it on a 0–10 scale, of “clean” ATP results for each of the 16 room sites (Table 1) in each of the 2 rooms tested per unit per week. The monthly composite score was calculated per unit and for all units combined. Five clinical units at 3 Nebraska hospitals of differing sizes were chosen for the intervention. Hospital A was a 635-bed acute care, academic, tertiary referral hospital in Omaha, Nebraska, for the University of Nebraska Medical Center (UNMC). Study units included a 40-bed general medical/ surgical unit (unit A1), a 32-bed telemetry unit (unit A2), and a 7-bed burn unit that has both burn and nonburn patients (unit A3). Hospital B is a 184-bed acute care hospital in western Nebraska; the study unit was an 18-bed intensive care unit (ICU). Hospital C is a 47-bed acute care hospital in northeast Nebraska; the study unit was a 9-bed ICU. Each hospital used their routine cleaning protocols during the study. Two control units at hospital A were chosen for the
Affiliations: 1. College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; 2. College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska; 3. College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska. Received October 10, 2013; accepted December 31, 2013; electronically published March 19, 2014. 䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3505-0014$15.00. DOI: 10.1086/675839
This content downloaded from 85.64.25.112 on Tue, 3 Jun 2014 08:05:01 AM All use subject to JSTOR Terms and Conditions
impact of atp detection and feedback on hospital room cleaning
table 1. Room Surface Size versus Cleanliness Surface Bathroom inner door handle Toilet seat Main light switch Nurse call light Patient phone Room chair arms Mattress Top surface/bedside table Bedrail Bedrail inside control panel Sink light switch External door handle High/low control lever on bedside table Toilet flusher Sink faucet handle Soap dispenser
Surface area, cm2
Clean,a %
567 351 203 136 126 105 100 100 100 100 95 85 82 78 60 56
83.5 83.7 86.7 74.4 76.1 53.1 93.3 79.3 72.7 50.8 87.5 88.9 61.5 73.1 61.0 82.8
note. ATP, adenosine triphosphate. a Defined as ATP less than 250 relative light units.
collection of infection surveillance data only, a 36-bed medical/surgical unit (A4) and a 49-bed cardiac unit (A5). These 2 units did not receive ATP assays after cleaning or education of EVS personnel. The study was approved by the institutional review boards (IRBs) at UNMC and hospital B; hospital C subcontracted with the UNMC IRB. All 3 hospitals are members of the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). ATP readings were obtained using the 3M Clean Trace ATP system, an ATP bioluminescence assay (3M Clean-Trace Surface ATP System; 3M). A sterile polystyrene swab was rubbed over a high-touch area for 30 seconds, placed in a plastic
tube and shaken for 30 seconds, and then placed in the portable handheld luminometer that provides a digital readout of the light generated by the luciferase reaction, expressed digitally as relative light units (RLUs). We selected the most widely used threshold for clean surfaces as readings below 250 RLU per surface.6,7 RLUs were not standardized to a per unit area measurement but were left as raw measurements regardless of the size of the area being tested to simulate likely real life use conditions. This study focused on trends in the percentage of clean surfaces rather than the absolute values of the ATP readings. Data Collection The infection preventionists (IPs) at hospitals B and C served as study coordinators, while a healthcare epidemiology research nurse served in this role at hospital A. At each hospital, the study coordinator was responsible for implementing educational activities as well as overseeing the ATP and HAI data collection. A physician infection control specialist provided on-site training at the initiation of the study and throughout the study period. The IP position at hospital B was filled by 3 individuals during the study period, but there were no interruptions in data collection. A true convenience sample of 2 rooms per week in each study unit ready for terminal cleaning were selected on the basis of availability. Study personnel were notified by EVS that a patient was discharged from the hospital, and the room was cleaned. EVS workers and their managers were unaware of which rooms were selected for testing. Information regarding which room was cleaned and which EVS personnel did the cleaning were collected confidentially and pooled at the unit level to protect the identity of the cleaners. Terminal cleaning was performed in a standard fashion,
table 2. Schedule of Educational Intervention Activities Study period 1
2
3
4 5 note.
565
Description of intervention ATP results feedback to EVS. EVS workers were given feedback on performance by a pooled score consisting of composite unit score (from 0 to 10) of room surfaces rated clean. Graphic displays were used to show trends in the composite scores over time, and monthly newsletters highlighted unit-specific composite monthly scores. A study introduction video was shared with the EVS workers at an initial meeting. Study engagement materials (eg, lunch bags, lanyards, buttons) were shared throughout the study. Hands-on use of ATP devices by EVS. EVS workers were given the opportunity to use the ATP device in a hospital room, under the direction of the site study nurse, including testing 3 room surfaces, cleaning, and then observing the improvement in ATP score after cleaning. Additional educational materials included a laminated pocket-size cleaning order and hightouch surfaces list in both English and Spanish. Education of EVS through an electronic game. The cleaning success of room surfaces was shared with EVS using the “Clean Sweep” electronic game. The user selected 3 high-touch surfaces for first, second, and third cleanest and least clean surfaces from a drop-down menu, then submitted the data to get feedback on their selection (see Figure 2). Additional rewards for performance. All EVS workers from each unit that improved were given a pizza luncheon upon release of the previous month’s scores. Washout period; no interventions
ATP, adenosine triphosphate; EVS, environmental services.
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figure 1. Screen shot of “Clean Sweep” electronic game for environmental services (EVS) workers. Developed by Stephen Smith, Instructional Technologist, University of Nebraska Medical Center College of Nursing.
involving collecting trash and linen, high dusting, wet dusting, wiping of surfaces with disinfectant (a quaternary ammonium compound), floor cleaning, bathroom cleaning, and room inspection. The room was then tested with the ATP device, generally 30–60 minutes after cleaning. Sampling consisted of ATP readings on 16 high-touch surfaces per room, as listed in Table 1.6,9-12 For each sample, the entire surface area of was swabbed except for large surfaces, like the mattress and bedside table, where a 10 # 10-cm template was used (Table 1). Study periods were limited to those in which data from all 5 sites were collected. In addition to cleaning score measurements over time, trends in HAIs were observed. Infections were detected by routine surveillance procedures at the respective hospitals. Central line–associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were observed by standard active surveillance, whereas Clostridium difficile infection, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococcus infections were observed by laboratory-based surveillance. Standard NHSN definitions for HAIs were used.13 HAIs were calculated per 1,000 patient days. Our study was not designed to analyze
the significance of change in HAI rates with cleanliness but reported the HAI rates for completeness. Educational Interventions A nurse educator from the UNMC College of Nursing worked with EVS and infection control to develop appropriate interventions. Educational interventions were introduced to EVS by site IPs for 4 consecutive 3-month periods (Table 2; Figure 1). The interventions were layered (eg, each successive intervention was added to the previous interventions. ATP data collection began April 1, 2011, and ended December 31, 3012. The study included a 6-month baseline period before implementation of the interventions and a 3-month washout period after the interventions were stopped. Analysis and Statistical Methods The effects of the interventions and their removal during washout were estimated using a generalized linear mixed model with a 250 RLU pass/fail cutoff as the outcome. The model estimated the likelihood of surface cleanliness across the different periods of the study (baseline, intervention pe-
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figure 2. Composite cleanliness scores during the study for each unit and overall score.
riods 1–4, and washout) while also modeling random effects for study site, observation (defined as the set of surfaces measured within a single room at a single point in time), and the surfaces themselves. Pairs of least-squares means were used to compare changes in the likelihood of surfaces being clean from one study period to the next. A similar model was used to analyze the likelihood of the item being clean versus the item’s surface area, again including random effects for surface type, observation, and site. A Spearman correlation between the surface area and the percentage clean was also used to assess a possible association. HAI rates were analyzed over time and between case and control groups using a Poisson regression model.
results The surface areas of the items ranged from 567 cm2 for the bathroom inner door handle to 56 cm2 for the soap dispenser. The site cleanliness ratings ranged from 93.3% for the mattress to 50.8% for the bedrail inside control panel. A model for whether a surface was clean by surface area (Table 1) did not reveal a significant association between site surface area and cleanliness (P p .52). The Spearman correlation between the surface area and the percentage clean demonstrated similar results (P p .49). The change in the cleanliness index (composite score on a 0–10 scale) of room surfaces per month that were above the “clean” threshold) is shown graphically in Figure 2. This reveals general improvement in scores with successive interventions and a trend toward decreased scores during the washout period. This figure displays trends for individual
units as well as an overall score for the 5 study units combined. Table 3 shows the actual numbers and percentages of surfaces that were clean using the 250 RLU cutoff for each intervention period. The likelihood of cleanliness increased throughout the 4 intervention periods before decreasing somewhat during the washout period. Comparison of least squares means from one study period to the next showed that each additional intervention resulted in a statistically significant increase in surface cleanliness (Table 3); however, our study was not designed to quantitatively compare the effects of the various interventions. Analysis of total HAIs that were measured in study and control units before, during, and after the intervention periods did not reveal any significant change in HAI rates during the study periods or any differences between study and control unit rates.
discussion It is recommended that infection control and EVS develop a program to assess terminal hospital room cleaning efficacy and use the results to provide feedback to improve room cleaning.1 ATP detection devices have the advantages of convenience and providing rapid results for prompt feedback to hospital cleaning personnel. Although an alternative method such as fluorescent dye shares some of these same advantages and uses, it has an element of subjectivity that is avoided with the use of ATP.9,14 The importance of EVS education is underscored by the poor baseline hospital room high-touch surface cleaning results, with approximately half of tested surfaces failing the
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table 3. Percentage of Clean Surfaces for Each Study Period and Comparisons between Study Periods Study period Baseline Intervention Intervention Intervention Intervention Washout Total
1 2 3 4
Total sites tested
Clean sites, %a
Adjacent periods comparison
P
4,030 2,031 1,879 1,865 1,893 1,647 13,345
44.0 55.0 66.8 75.6 86.5 82.8 61.3
... Baseline vs intervention 1 Intervention 1 vs intervention 2 Intervention 2 vs intervention 3 Intervention 3 vs intervention 4 Intervention 4 vs washout
!.001 !.001 !.002 !.001
.064
note. ATP, adenosine triphosphate. a Defined as ATP less than 250 relative light units.
after-cleaning assessment.1,9 Our baseline composite percentage of surfaces after cleaning that scored as “clean” (less than 250 RLU) was in that range (46%) but improved with each intervention to 79% in the final period (Table 3). It decreased to 76% in the 3-month washout period when all interventions were withdrawn. Each intervention resulted in a statistically significant improvement in performance, but we were unable to determine whether a particular intervention was superior to other interventions. In spite of the differences in hospital size and EVS programs, all units demonstrated improvement during the study. The lack of a correlation between surface area and cleaning score may be confounded by site complexity. The cleanest surface was the mattress, which is flat and easy to clean, whereas the site with the lowest cleanliness rating, the bedrail control panel, is a complex surface; however, a formal analysis of site complexity and cleanliness was not done. Although it is agreed that improvement in environmental cleaning is likely to decrease HAIs, standard surveillance did not reveal a significant change in HAI rates during the study. However, the primary purpose of our study was to evaluate the feasibility and effectiveness of the environmental ATP assay to measure trends in hospital rooms after cleaning with time. This portable and rapid assay can be used to test hightouch areas in hospital patient rooms after cleaning and observe trends with time to provide feedback and improve cleaning performance. It remains to be seen what effect implementation of ATP monitoring might have on HAI rates, especially if the monitoring were conducted facility-wide or applied to daily cleaning, rather than to terminal only. There are insufficient data on specific educational interventions for maximizing hospital room cleaning efficacy.15 A variety of methods have been recommended (eg, didactic sessions, cleaning checklists, cleaning demonstrations, and direct observation of the EVS worker), and feedback is an important part of the educational process.1,14-18 We introduced multiple layered educational interventions and noted an improvement in composite cleaning scores with each subsequent intervention. The educational interventions were designed to provide feedback; emphasize the importance of environmen-
tal cleaning, especially room high touch areas; and reward cleaning performance. Educational methods in this study hinged on adult learning theory, including the importance of self-direction, experiential learning, learning readiness, and the immediate application of new knowledge to current problems. Cleanliness in hospitals has been shown to improve with education and training of cleaning personnel.19 Guerrero et al20 demonstrated the importance of active interventions and direct interaction in improving hospital room cleaning by EVS. Adding a gaming element to competency training can be more engaging and helps to educate learners with different levels of learning ability.21 There was likely less value in obtaining the correct answers than in the consistent redirection of attention to cleaning of neglected high-touch surfaces. Limitations of this study include dependence of the ATP score on the manufacturer device22 and variable correlation with other methods that measure hospital environmental cleanliness.6,7 Use of the same device to measure the same room surfaces over time eliminates some concerns related to monitoring trends. Second, although all interventions demonstrated significant improvement in cleanliness scores, the study was not designed to compare the relative potency of the various interventions. The washout period did suggest that removal of the ATP program would lead to a decrease in cleaning efficacy, but the washout period was only 3 months. Third, use of the ATP device or the electronic educational game may not be financially feasible for smaller hospitals. Our study was not designed to correlate changes in HAIs with cleanliness efficacy. Finally, our educational feedback program was only used for terminal cleaning. Nevertheless, the ATP detection device can be used to provide timely feedback to EVS workers on the effectiveness of hospital environmental cleaning. Feedback of ATP results to EVS workers combined with various layered educational interventions resulted in significantly better ATP scores. Future studies should address the comparative efficacy of various educational interventions, the durability of feedback programs, the number of surfaces needed for representative sampling, and the cost effectiveness of the ATP detection method.
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impact of atp detection and feedback on hospital room cleaning
acknowledgments Financial support. The US Army Medical Research and Materiel Command and the Telemedicine and Advanced Technology Research Center at Fort Detrick, Maryland, provided funding for this study (W81XWH-10-1-0703). Potential conflicts of interest. M.E.R. reports that he serves on an advisory board for 3M and has a research contract from 3M awarded to University of Nebraska Medical Center. All other authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Address correspondence to Philip W. Smith, MD, College of Medicine, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198 ([email protected]).
11.
12.
13.
14.
references 1. Guh A, Carling P; Environmental Evaluation Workgroup. Options for evaluating environmental cleaning. http://www.cdc .gov/hai/toolkits/evaluating-environmental-cleaning.html. Updated 2010. Accessed October 1, 2013. 2. Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control 2013;41:S6–S11. 3. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006;166: 1945–1951. 4. Carling PC, Parry MF, Von Beheren SM; Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol 2008;29:1–7. 5. Boyce JM, Havill NL, Lipka A, Havill H, Rizvani R. Variations in hospital daily cleaning practices. Infect Control Hosp Epidemiol 2010;31:99–101. 6. Boyce JM, Havill NL, Havill HL, Mangione E, Dumigan DG, Moore BA. Comparison of fluorescent marker systems with 2 quantitative methods of assessing terminal cleaning practices. Infect Control Hosp Epidemiol 2011;32:1187–1193. 7. Smith P, Sayles H, Hewlett AL, Cavalieri R, Gibbs S, Rupp M. A study of three methods for assessment of hospital environmental cleaning. Healthcare Infect 2013;18:80–85. 8. Sherlock O, O’Connell N, Creamer E, Humphreys H. Is it really clean? an evaluation of the efficacy of four methods for determining hospital cleanliness. J Hosp Infect 2009;72:140–146. 9. Carling PC, Parry MM, Rupp ME, et al. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol 2008;29:1035–1041. 10. Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun
15.
16.
17.
18.
19.
20.
21. 22.
569
O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 2009;30:678–684. Smith PW, Gibbs S, Sayles H, Hewlett A, Rupp ME, Iwen PC. Observations on hospital room contamination testing. Healthcare Infection 2013;18:10–13. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850–853. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309–332. 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;38:387–392. Boyce JM, Havill NL, Dumigan DG, Golbiewski M, Balogun O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices using an ATP bioluminescence assay. Paper presented at: Society for Healthcare Epidemiology of America Annual Scientific Meeting; April 5–8, 2008; Orlando, Florida (Poster 276). Matlow AG, Wray R, Richardson SE. Attitudes and beliefs, not just knowledge, influence the effectiveness of environmental cleaning by environmental service workers. Am J Infect Control 2012;40:260–262. Rebmann T, Aureden K; Association for Professionals in Infection Control and Epidemiology. Preventing methicillin-resistant Staphylococcus aureus transmission in long-term care facilities: an executive summary of the APIC Elimination Guide. Am J Infect Control 2011;39:235–238. Havill NL. Best practices in disinfection of noncritical surfaces in the health care setting: creating a bundle for success. Am J Infect Control 2013;41:S26–S30. Aziz A. Can education and training for domestic staff increase awareness of infection control practices and improve cleanliness within hospitals? J Infect Preven 2009;10:171–177. Guerrero DM, Carling PC, Jury LA, Ponnada S, Nerandzic MM, Donskey CJ. Beyond the Hawthorne effect: reduction of Clostridium difficile environmental contamination through active intervention to improve cleaning practices. Infect Control Hosp Epidemiol 2013;34:524–526. Pauli P. Using games to demonstrate competency. J Nurses Staff Dev 2005;21:272–276. Whiteley GS, Derry C, Glasbey T. Reliability testing for portable adenosine triphosphate bioluminometers. Infect Control Hosp Epidemiol 2013;34:538–540.
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