Diagnostic assessment of different environmental cleaning monitoring methods

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.

Assessment of ATP-Bioluminescence and Dipslide Sampling to Determine the Efficacy of Slaughterhouse Cleaning and Disinfection Compared with Total Aerobic and Enterobacterales Counts

Inadequate cleaning and disinfection (C&D) in slaughterhouses can cause bacterial contamination of meat, resulting in foodborne disease and reduced meat quality. Different methods for monitoring the efficacy of C&D procedures are available, but few studies have assessed their reliability. This study examined C&D efficacy in slaughterhouses and evaluated the diagnostic performance of methods for measuring surface hygiene. One red meat and one poultry slaughterhouse in Sweden were each visited on six occasions before and six occasions after C&D. Sampling points were sampled with: swabbing and plating for total aerobic bacteria (TAB) and Enterobacterales (EB); dipslides for total viable count; and ATP-bioluminescence tests. To evaluate the diagnostic performance of the dipslide and ATP-bioluminescence methods, the results were compared with (TAB) as a reference. In total, 626 samples were collected. For the majority of samples, TAB was lower after than before C&D and EB were mainly detected before C&D, indicating C&D efficacy. Greater reductions in mean TAB were observed in processing areas (2.2 and 2.8 log CFU/100 cm2 in red meat and poultry slaughterhouse, respectively) than in slaughter areas (1.3 log CFU/100 cm2 in both slaughterhouses). Approximately half of all samples were assessed as non acceptably clean (52% for red meat and 46% for poultry slaughterhouse) according to previously published thresholds. Critical food contact surfaces that were insufficiently cleaned and disinfected were plucking fingers, shackles, and a post-dehairing table. Cleaning and disinfection of drains and floors were inadequate. The ATP-bioluminescence method showed low specificity compared with the reference (TAB) in both the red meat (0.30) and poultry slaughterhouses (0.64). The sensitivity of dipslides was low (0.26) in the red meat slaughterhouse compared with TAB. A combination of ATP-bioluminescence and dipslides could provide more accurate estimates of C&D efficacy.

Stopping Hospital Infections With Environmental Services (SHINE): A Cluster-randomized Trial of Intensive Monitoring Methods for Terminal Room Cleaning on Rates of Multidrug-resistant Organisms in the Intensive Care Unit

BACKGROUND

Multidrug-resistant organisms (MDROs) frequently contaminate hospital environments. We performed a multicenter, cluster-randomized, crossover trial of 2 methods for monitoring of terminal cleaning effectiveness.

METHODS

Six intensive care units (ICUs) at 3 medical centers received both interventions sequentially, in randomized order. Ten surfaces were surveyed each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services staff in real time with failing surfaces recleaned. We measured monthly rates of MDRO infection or colonization, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and MDR gram-negative bacilli (MDR-GNB) during a 12-month baseline period and sequential 6-month intervention periods, separated by a 2-month washout. Primary analysis compared only the randomized intervention periods, whereas secondary analysis included the baseline.

RESULTS

The ATP method was associated with a reduction in incidence rate of MDRO infection or colonization compared with the UV/F period (incidence rate ratio [IRR] 0.876; 95% confidence interval [CI], 0.807-0.951; P = .002). Including the baseline period, the ATP method was associated with reduced infection with MDROs (IRR 0.924; 95% CI, 0.855-0.998; P = .04), and MDR-GNB infection or colonization (IRR 0.856; 95% CI, 0.825-0.887; P < .001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turnaround time increased by a median of 1 minute with the ATP intervention and 4.5 minutes with UV/F compared with baseline.

CONCLUSIONS

Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a reduction of MDRO infection and colonization.

Prevention of Infection due to Clostridium (Clostridioides) difficile

Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.

The correlation between ATP measurement and microbial contamination of inanimate surfaces

Background

The objective of this study was to determine the correlation between adenosine triphosphate (ATP) measurements and microbial contamination using a standardized method. Secondarily, analyzing reproducibility of ATP measurements and aerobic colony counts (ACC’s) on the same surface.

Methods

ATP measurements and ACC’s were conducted on 10 pre-defined fomites in a hospital and nursing home setting. Per fomite two ATP measurements and two agar plate measurements were conducted, each measurement was conducted on a 25 cm² surface. Both measurements were compared and analyzed for correlation.

Results

In total 200 paired measurements were conducted, 200 ATP measurements and 200 ACC’s. The mean of all ATP measurements tested on the same surface was calculated, as was for all 200 ACC’s. There was a strong correlation between the mean of two ATP measurements on two different sites on the same fomite (R = 0.800, p < 0.001) as well as between two ACC measurements on the same fomite (R = 0.667, p < 0.001). A much weaker correlation was found between RLU values and ACC’s (R = 0.244, p < 0.001).

Conclusions

Reproducibility of ATP measurements and ACC’s on the same fomite was good. However, the correlation between RLU values and ACC’s on hospital surfaces was much lower. This may be explained by the wide variety of biological material that is measured with ATP, of which the bacterial load is only one of many components. ATP measurement can be used to give a quantifiable outcome for the rating of cleanliness in health care facilities, however the results cannot be translated into the level of microbial contamination.

ATP Bioluminescence for Assessing the Efficacy of the Manual Cleaning Procedure during the Reprocessing of Reusable Surgical Instruments

Achieving sterilization by adopting proper practices is essential to ensure that surgical instruments do not transmit microorganisms to patients. As the effectiveness of sterilization mandates effective cleaning, it is necessary to verify the success of cleaning procedures. In this study, we used the adenosine triphosphate (ATP) bioluminescence method for assessing the efficacy of the manual cleaning procedure during the reprocessing of reusable surgical instruments. The ATP bioluminescence assay was performed on 140 surgical instruments of 12 different types, both before being cleaned (baseline) and after each of the cleaning procedures (i.e., decontamination, manual washing, drying, and visual inspection). For each instrument, two swabs were used as follows: one to sample the entire surface (test point 1) and the other to sample the most difficult part of the surface to clean (test point 2). Overall, for each type of instrument, there was a decrease in contamination ranging from 99.6 to >99.9% (log reduction from 2.40 to 3.76). Thus, in order to standardize the assessment of cleanliness, it may be useful to introduce the bioluminescence method into the daily routine or, at least, at regular time intervals as a complementary check combined with visual inspection. This would allow real-time verification of the achievement of an adequate level of cleanliness.

Overview of Portable Assays for the Detection of Mycotoxins, Allergens, and Sanitation Monitoring

BACKGROUND

Many food recalls are related to the presence of undeclared allergens and microorganisms in food products. To reduce these occurrences, portable diagnostic assay kits are available to quantitate mycotoxins, to detect allergens and gluten in foods and on environmental surfaces, and for sanitation monitoring.

OBJECTIVE

This article reviews diagnostic kits that can detect sources of contamination in food and ingredients as well as on surfaces and clean-in-place rinses.

METHOD

Mycotoxins and gluten were detected using lateral flow diagnostic assays. Sanitation monitoring of surfaces was completed using a chemiluminescent assay to detect adenosine 5'-triphosphate disodium salt hydrate (ATP) and another assay to detect protein.

RESULTS

Gluten was detected at 10 ppm in spiked commodities and on wet and dry surfaces at 2.5 µg/100cm2. Deoxynivalenol was quantitated in dry distillers grains plus solubles and mean results were within two SDs of those determined by HPLC. The chemiluminescent assay had an LOD of 6 fmol of ATP and was able to detect a 1:10 000 dilution of orange juice from surfaces. The protein assay detected 5 µg of bovine serum albumin (BSA) directly applied to the sampler, 100 µg of BSA on surfaces, and detected 1:10 dilutions of Greek yogurt and raw beef from surfaces.

CONCLUSIONS

Portable diagnostic kits evaluated in this work provided accurate, rapid, and sensitive results for detection of mycotoxins, gluten, proteins, and ATP. These methods can be used in facilities with minimal training and provide results that are important to ensure food safety.

HIGHLIGHTS

Portable methods to detect gluten, mycotoxins, proteins, and ATP are presented.

Assessment of percent positive agreement between fluorescent marker and ATPase for environmental cleaning monitoring during sequential application in an intensive care unit

Terminal room cleaning is critical in preventing pathogen transmission; however, the optimal cleaning effectiveness assessment modality is still being investigated. We sequentially compared cleanliness assessment agreement between a fluorescent marker and an adenosine triphosphate bioluminescence method, finding no significant differences between modalities.

Effectiveness of clinical surface cleaning and disinfection: evaluation methods

OBJECTIVE

To discuss the methods employed to evaluate the effectiveness of clinical surface cleaning and disinfection (C&D).

METHOD

This is a theoretical reflection based on scientific studies and the experience of the authors. Knowledge and current gaps, the need for further studies, and practical application of the methods were approached.

RESULTS

There are four main methods used to evaluate the effectiveness of clinical surface C&D: visual inspection, fluorescent markers, microbiological cultures, and adenosine triphosphate (ATP) bioluminescence. The first two are used to evaluate the process and to predict adherence to protocols by the staff, and the last two are employed to evaluate the results, therefore being the most relevant to assess the risk of infection.

FINAL CONSIDERATIONS

The ideal method was not found, because all of them showed limitations. There is a need for strategies to optimize the precision of these methods.

Fluorescent tagging for environmental surface cleaning surveillance in a veterinary hospital

OBJECTIVES

To evaluate the use of fluorescent tagging for environmental surface cleaning surveillance in a small animal veterinary hospital and identify factors associated with tag removal.

MATERIALS AND METHODS

Over 5.5 weeks, a commercial fluorescent dye (Glo Germ) was used to tag (mark) surfaces in a small animal veterinary teaching hospital. Twenty-four hours after tagging, cleaning was assessed with a black light (UV-A source). Surfaces were recorded as cleaned based on complete removal of fluorescent tagging at assessment. Proportions cleaned were calculated overall and by predictors (i.e. surface location/type, primary nature of surface contact - animal/human, week of study).

RESULTS

A total of 4984 surfaces were tagged and assessed. Overall cleaning was 50%. Cleaning varied by surface/object (range: 2 to 100%) and hospital location (4 to 78%). Surfaces designated as having primarily animal contact were cleaned more frequently than those with primarily human contact (75%, 42%; P<0.001). Cleaning varied over the study period (range by week: 45 to 54%;); a significant trend was not identified.

CLINICAL SIGNIFICANCE

Key surfaces in the small animal veterinary practice environment are unlikely to be adequately cleaned, posing a concern for animal and human health. Commercial products can be effectively used to asses environmental cleaning with findings used to target clinic-specific barriers to improve cleaning and reduce hospital-associated infections.

Comparative evaluation of a novel fluorescent marker and environmental surface cultures to assess the efficacy of environmental cleaning practices at a tertiary care hospital

BACKGROUND

Cleaning high-touch surfaces serves as a crucial step towards controlling the transmission of multidrug-resistant pathogens in hospital environments. The process can be made most effective if scientifically monitored using a simple, feasible and reliable technique, especially in resource-poor settings.

AIM

To identify a novel florescent marker (FM) comparable to the already existing commercial FM systems and to assess its efficacy in evaluating cleaning of high-touch surfaces in a hospital environment.

METHODS

A liquid detergent used for washing purposes was identified as a novel FM. Pre- and post-cleaning sampling were performed from 250 high-touch surfaces in different patient-care areas using this marker and aerobic colony counts. Concordance between the two methods was assessed and compared by Cohen's kappa coefficient. The sensitivity, specificity, positive predictive and negative predictive values for the new FM method were calculated against the microbiological method.

FINDINGS

A good correlation (κ = 0.60) with overall concordance of 79.6% was observed between the two methods. The sensitivity, specificity, positive predictive value and negative predictive value of the FM were 79.58% (95% confidence interval (CI): 72-85.85%), 79.63% (95% CI: 70.79-86.78), 83.70% (95% CI: 76.38-89.50) and 74.78% (95% CI: 65.83-82.38), respectively.

CONCLUSIONS

The FM used in the present study proved to be a simple and cost-effective alternative to commercially available FMs for assessing environmental cleaning practices on a daily basis in resource-poor settings. Additional studies making direct comparisons of the FM used here with the established FMs are warranted before it can be generalized for use.

Application of a fluorescent marker with quantitative bioburden methods to assess cleanliness

BACKGROUND

Improvement of environmental cleaning in hospitals has been shown to decrease in-hospital cross transmission of pathogens. Several objective methods, including aerobic colony counts (ACCs), the adenosine triphosphate (ATP) bioluminescence assay, and the fluorescent marker method have been developed to assess cleanliness. However, the standard interpretation of cleanliness using the fluorescent marker method remains uncertain.

OBJECTIVE

To assess the fluorescent marker method as a tool for determining the effectiveness of hospital cleaning.

DESIGN

A prospective survey study.

SETTING

An academic medical center.

METHODS

The same 10 high-touch surfaces were tested after each terminal cleaning using (1) the fluorescent marker method, (2) the ATP assay, and (3) the ACC method. Using the fluorescent marker method under study, surfaces were classified as totally clean, partially clean, or not clean. The ACC method was used as the standard for comparison.

RESULTS

According to the fluorescent marker method, of the 830 high-touch surfaces, 321 surfaces (38.7%) were totally clean (TC group), 84 surfaces (10.1%) were partially clean (PC group), and 425 surfaces (51.2%) were not clean (NC group). The TC group had significantly lower ATP and ACC values (mean ± SD, 428.7 ± 1,180.0 relative light units [RLU] and 15.6 ± 77.3 colony forming units [CFU]/100 cm2) than the PC group (1,386.8 ± 2,434.0 RLU and 34.9 ± 87.2 CFU/100 cm2) and the NC group (1,132.9 ± 2,976.1 RLU and 46.8 ± 119.2 CFU/100 cm2).

CONCLUSIONS

The fluorescent marker method provided a simple, reliable, and real-time assessment of environmental cleaning in hospitals. Our results indicate that only a surface determined to be totally clean using the fluorescent marker method could be considered clean.

Efficiency of cleaning and disinfection of surfaces: correlation between assessment methods

OBJECTIVE

to assess the correlation among the ATP-bioluminescence assay, visual inspection and microbiological culture in monitoring the efficiency of cleaning and disinfection (C&D) of high-touch clinical surfaces (HTCS) in a walk-in emergency care unit.

METHOD

a prospective and comparative study was carried out from March to June 2015, in which five HTCS were sampled before and after C&D by means of the three methods. The HTCS were considered dirty when dust, waste, humidity and stains were detected in visual inspection; when ≥2.5 colony forming units per cm2 were found in culture; when ≥5 relative light units per cm2 were found at the ATP-bioluminescence assay.

RESULTS

720 analyses were performed, 240 per method. The overall rates of clean surfaces per visual inspection, culture and ATP-bioluminescence assay were 8.3%, 20.8% and 44.2% before C&D, and 92.5%, 50% and 84.2% after C&D, respectively (p<0.001). There were only occasional statistically significant relationships between methods.

CONCLUSION

the methods did not present a good correlation, neither quantitative nor qualitatively.

Reducing environmental surface contamination in healthcare settings: A statewide collaborative

To help reduce healthcare-associated infection (HAI) rates across the state, the Maryland Patient Safety Center's Clean Collaborative (Collaborative) supported 17 acute care hospitals, 3 long-term care facilities, and 4 ambulatory surgical centers in improving environmental surface cleaning, with the goal of reducing rates of Clostridium difficile infection, which the Collaborative team selected as a proxy for HAIs. Eighty-eight percent of participating facilities achieved the program goal of a 10% reduction in relative light units from the baseline month to the final month of the Collaborative. In addition, participating facilities achieved a 14.2% decrease in C. difficile rates compared to only a 5.9% decrease among non-participating facilities (in Maryland).

Breaking the Chain of Infection in Older Adults: A Review of Risk Factors and Strategies for Preventing Device-Related Infections

Device-related infections (DRIs) are a significant cause of morbidity and mortality among older adults. Indwelling devices (urinary catheters, percutaneous feeding tubes, and central venous catheters) are frequently used in this vulnerable population. Indwelling devices provide a portal of entry for pathogenic organisms to invade a susceptible host and cause infection and are an important target for infection prevention and antimicrobial stewardship efforts. Within the "Chain of Infection" that leads to DRIs in older adults, multiple opportunities exist to implement interventions that "break the links" and reduce colonization with multidrug-resistant organisms, reduce infections, and improve antimicrobial use.

Effectiveness of Surface Cleaning and Disinfection in a Brazilian Healthcare Facility

Background

Failures in the processes of cleaning and disinfecting health service surfaces may result in the spread and transfer of pathogens that are often associated with healthcare-related infections and outbreaks.

Aims

To assess the effectiveness of environmental surface cleaning and disinfection in a hospital clinic.

Method

The study was conducted in a nursing ward with 45 beds. A total of 80 samples from five high-touch surfaces were evaluated before and after cleaning and disinfection, using the following methods: visual inspection, adenosine triphosphate bioluminescence assay, aerobic colony count, Staphylococcus aureus colony count, and evaluation of resistance to methicillin. The data analysis used nonparametric comparative and correlative tests to observe any differences in the pre- and post- cleaning and disinfection results for the surfaces assessed.

Results

Effective cleaning and disinfection had a significant effect on only two surfaces when measured for the presence of adenosine triphosphate, the inner bathroom door handle (p=0.007) and the toilet bowl (p=0.01). When evaluated for Staphylococcus aureus colony count, the toilet flush handle also demonstrated a significant effect (p=0.04).

Conclusion

The effectiveness of cleaning and disinfection of the surfaces tested was not satisfactory. An educational intervention is recommended for the cleaning and disinfection staff and the nursing team at the healthcare facility.

Relevance to Clinical Practice

The data in the study revealed that daily hospital cleaning and disinfection in the sampled sites are not sufficient in medical and surgical wards. Hospital cleanliness must be reevaluated from the point of view of materials, such as an adequate supply of clean cloths, in addition to establishing more precise cleanliness protocols and accurate monitoring systems.

AVALIAÇÃO DA EFICIÊNCIA DA LIMPEZA E DESINFECÇÃO DE SUPERFÍCIES EM UMA UNIDADE BÁSICA DE SAÚDE

RESUMO Objetivo: avaliar o efeito de intervenções educativasna limpeza e desinfecção de superfícies em uma unidade básica de saúde. Métodos: trata-se de um estudo prospectivo, analítico com abordagem quantitativa. O estudo foi realizado em uma unidade básica de saúde, onde atuam duas equipes da Estratégia de Saúde da Família. Optou-se por avaliar a limpeza e desinfecção das superfícies: carrinho de curativo, balcão da recepção, mesa ginecológica, maca do paciente e mesa de consulta de enfermagem, utilizando-se dos métodos de monitoramento: avaliação visual, contagem de unidades formadoras de colônias e mensuração de adenosina trifosfato. Utilizaram-se, para a análise estatística, o teste de postos de Wilcoxon e o teste de Mann-Whitney, considerou-se nível de significância de 5% ou (p<0,05). Resultados: obteve-se um total de 720 avaliações realizadas ao término de todas as fases. Observou-se na fase I uma taxa de reprovação de 57,5%, 20,0% e 90,0%; após a intervenção educativa, os quantitativos de reprovação em curto prazo diminuíram para 0,0%, 2,5,0% e 50,0% (dados da fase III) e, em longo prazo, para 5,0%, 0,0% e 65% (dados da fase IV) para os métodos visual, adenosina trifosfato e cultura, respectivamente. A inspeção visual foi o método que apresentou maior frequência de superfícies reprovadas nas fases I e IV. Conclusão: houve redução da carga microbiana e valores das leituras de adenosina trifosfato; embora essa redução não tenha sido estatisticamente significativa em todas as superfícies. Constatou-se que a intervenção educativa foi eficiente.

Practical Approaches for Assessment of Daily and Post-discharge Room Disinfection in Healthcare Facilities

PURPOSE OF REVIEW

Cleaning and disinfection in healthcare facilities is essential to ensure patient safety. This review examines practical strategies used to assess and improve the effectiveness of daily and post-discharge manual cleaning in healthcare facilities.

RECENT FINDINGS

Effective implementation of cleaning interventions requires objective monitoring of staff performance with regular feedback on performance. Use of fluorescent markers to assess thoroughness of cleaning and measurement of residual ATP can provide rapid and objective feedback to personnel and have been associated with improved cleaning. Direct observation of cleaning and interviews with front-line staff are useful to identify variations and deficiencies in practice that may not be detected by other methods. Although not recommended for routine monitoring, cultures can be helpful for outbreak investigations. Monitoring and feedback can be effective in improving cleaning and disinfection in healthcare facilities. Ongoing commitment within institutions is needed to sustain successful cleaning and disinfection programs.

Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

BACKGROUND

Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

METHODS

This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions-feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

RESULTS

We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

CONCLUSIONS

The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

The therapeutic impacts of environmental design interventions on wellness in clinical settings: A narrative review

PURPOSE

The aim of this review is to document the role of physical environmental factors in clinical environments and their impact on patients and staff wellness with a particular focus on physical and mental healthcare.

METHODS

Data sources comprised relevant English language articles and the results of literature search of ISI Web of Knowledge, PubMed, Scopus, ProQuest Central, MEDLINE, and Google.

RESULTS

Incorporating physical environmental factors into hospital design can facilitate better user satisfaction, efficiency and organisational outcomes. Many of the design interventions convey positive distractions for patients and staff, in terms of views of pleasant outside vistas, soothing sound, artwork and music.

CONCLUSIONS

Well-designed physical settings play an important role in the healing process of patients in health care facilities. The challenge then is to fully understand that role in the ecological context of health care. Other contributors are possible and should be explored in further research.

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.

Failure analysis in the identification of synergies between cleaning monitoring methods

BACKGROUND

The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method.

METHODS

FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks.

RESULTS

FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation.

CONCLUSIONS

When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method.

How clean is clean: a new approach to assess and enhance environmental cleaning and disinfection in an acute tertiary care facility

Traditional environmental cleaning monitoring through visual assessment can identify gross lapses in practice. However, in recent years the limitations underlying this need for ongoing compliance with cleaning and disinfection policies in the patient's immediate surroundings have become widely recognised. The value of objectively monitoring and improving environmental cleaning and disinfection in healthcare settings is becoming increasingly identified as a crucial element of strategies to mitigate the transmission of healthcare-associated infections. Mafraq Hospital has adopted a new method using an invisible fluorescent marker system to target on surfaces in patient's immediate surroundings. Evaluation of at least 30 surfaces and objects in patient rooms revealed that only 11% of targets had been cleaned. Simulation training, educational interventions, empowerment, change involvement and acknowledgment were executed, leading to a sustained improvement of 77% in both quarter 2 and 3 of 2013 in cleaning and disinfecting of all surfaces and objects.

Best practice in healthcare environment decontamination

There is now strong evidence that surface contamination is linked to healthcare-associated infections (HCAIs). Cleaning and disinfection should be sufficient to decrease the microbial bioburden from surfaces in healthcare settings, and, overall, help in decreasing infections. It is, however, not necessarily the case. Evidence suggests that there is a link between educational interventions and a reduction in infections. To improve the overall efficacy and appropriate usage of disinfectants, manufacturers need to engage with the end users in providing clear claim information and product usage instructions. This review provides a clear analysis of the scientific evidence supporting the role of surfaces in HCAIs and the role of education in decreasing such infections. It also examines the debate opposing the use of cleaning versus disinfection in healthcare settings.

Variation in detection limits between bacterial growth phases and precision of an ATP bioluminescence system

To determine the detection limits of the SystemSure Plus, Escherichia coli and Staphylococcus aureus growth curve samples were taken in lag (1 h), log (6 h), stationary (12 h) and death phases (E. coli 144 h, Staph. aureus 72 h). At each time point, the log10 CFU ml(-1) was determined for the dilution where the SystemSure read 0 relative light units (RLU). Average detection limits were E. coli: lag 6·27, log 5·88, stationary 7·45 and death 6·88; Staph. aureus: lag 4·37, log 5·15, stationary 7·88 and death 7·57. Between-run precision was determined with positive control; within-run precision with positive control, lag and log growth for each bacteria. Within-run precision mean RLU (CV): positive control 274 (12%), E. coli lag 1 (63%), log 2173 RLU (19%), Staph. aureus lag 2 (58%) and log 5535 (18%). Between-run precision was 232 (16%). The precision is adequate with most values within the 95% confidence interval. The detection limit varied by 3·51 log10 for Staph. aureus and 1·47 log10 for E. coli. The lowest detection limits were during E. coli log and Staph. aureus lag phases; the highest was during stationary phase. These results suggest that organism identification and growth phase both impact ATP RLU readings.

SIGNIFICANCE AND IMPACT OF THE STUDY

Surface hygiene is a critical component of food safety and infection control; increasingly, ATP detection by bioluminescence is used to evaluate surface hygiene and effective cleaning. This is the first study to show that the number of living and potentially infectious bacteria remaining when the device reads zero varies between the different bacterial life cycle phases: lag, log, stationary and death. ATP device users need to be aware of this information to use the devices appropriately.