Options for Evaluating Environmental Cleaning

Prepared by:
Alice Guh, MD, MPH¹
Philip Carling, MD²
Environmental Evaluation Workgroup³
December 2010

¹1Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
²Carney Hospital and Boston University School of Medicine, Boston, MA; Dr. Philip Carling has been compensated as a consultant of Ecolab and Steris. He owns a patent for the fluorescent targeting evaluation system described in this document (DAZO Fluorescent Marking Gel).
³Brian Koll, Beth Israel Medical Center, New York, NY; Marion Kainer and Ellen Borchers, Tennessee Department of Health, Nashville, TN; and Brandi Jordan, Illinois Department of Public Health, Chicago, IL

Introduction

In view of the evidence that transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs to optimize the thoroughness of high touch surface cleaning as part of terminal room cleaning at the time of discharge or transfer of patients.  Since dedicated resources to implement objective monitoring programs may need to be developed, hospitals can initially implement a basic or Level I program, the elements of which are outlined below.  Some hospitals should consider implementing the advanced or Level II program from the start, particularly those with increased rates of infection caused by healthcare acquired pathogens (e.g., high Clostridium difficile infection rate). All hospitals that have successfully achieved a Level I program should advance to Level II.

At present, the objective monitoring of the cleaning process of certain high touch surfaces (e.g., the curtain that separates patient beds) beyond those outlined in the attached checklist is not well defined.  Additionally, there is no standard method for measuring actual cleanliness of surfaces or the achievement of certain cleaning parameters (e.g., adequate contact time of disinfectant) or for defining the level of microbial contamination that correlates with good or poor environmental hygienic practices.  As our understanding of these issues evolve and a standardization of assessment in these respective areas can be developed and practically implemented, hospitals that have obtained a high compliance rate with surface cleaning as outlined in the Level II program are encouraged to advance their efforts in optimizing environmental hygienic practices. 

Level I Program

Elements of the program:

1. The program will be an infection preventionist/hospital epidemiologist infection prevention &control (IPC) based program internally coordinated and maintained through environmental services (ES) management level participation. The goal should be seen as a joint (IPC/ES), team effort during planning implementation and ongoing follow-up phases.
2. Each program will be hospital-specific and based on a joint (IC/ES) definition of institutional expectations consistent with the CDC standards1,2 and the attached check list.  The responsibilities of ES staff and other hospital personnel for cleaning high touch surfaces (e.g., equipment in ICU rooms) will be clearly defined.
3. Structured education of the ES staff to define programmatic and institutional expectations will be carried out and the proportion of ES staff who participate will be monitored (see Elements of the Educational Intervention – Appendix A).
4. Development of measures for monitoring along with methods and identified staff for carrying out monitoring will be undertaken by the IPC/ES team. Monitoring measures may include competency evaluation of ES staff by ES management, IPC staff or, preferably, both. Teams are also encouraged to utilize patient satisfaction survey results in developing measures. Regular ongoing structured monitoring of the program will be performed and documented. 
5. Interventions to optimize the thoroughness of terminal room cleaning and disinfection will be a standing agenda item for the Infection Control Committee (ICC) or Quality Committee as appropriate for the facility.
6. Consideration of the feasibility of moving to the Level II program will be discussed by the ICC and documented in the committee minutes.

Reporting:

Results should be reported to the ICC and facility leadership.

Level II Program

Elements of the Program

1. The program will be an infection preventionist/hospital epidemiologist infection prevention & control (IPC) based program internally coordinated and maintained through environmental services (ES) management level participation. The goal should be seen as a joint (IPC/ES), team effort during planning implementation and ongoing follow-up phases.
2. Each program will be hospital-specific and based on a joint (IC/ES) definition of institutional expectations consistent with the CDC standards1,2 and the attached check list. The responsibilities of ES staff and other hospital personnel for cleaning high touch surfaces (e.g., equipment in ICU rooms) will be clearly defined.
3. Either covertly or in conjunction with ES staff, an objective assessment of the terminal room thoroughness of surface disinfection cleaning will be done using one or more of the methods discussed below (see Objective Methods for Evaluating Environmental Hygiene – Appendix B) to document the pre-intervention thoroughness of disinfection cleaning (generally referred to as the “TDC Score” calculated as # of objects cleaned / total # of objects evaluated X 100). Such results will be maintained by the institution and used internally to optimize programmatic and educational interventions.
4. Structured education of the ES staff to define programmatic and institutional expectations will be carried out and the proportion of ES staff who participate will be monitored. It would be expected that the results of the pre-intervention objective evaluation of disinfection cleaning be incorporated into the ES educational activity in a non-punitive manner (see Elements of the Educational Intervention – Appendix A).
5. Scheduled ongoing monitoring of the TDC cleaning using one or more of the objective monitoring approaches discussed in Appendix B will be performed at least three times a year. The monitoring will use a projected sample size based on the previous level of TDC in order to detect a 10-20% change in performance (see Sample Size Determination – Appendix C).  The results will be recorded in an excel spreadsheet to calculate aggregate TDC scores (see Appendix D).
6. The results of the objective monitoring program and the objectively developed TDC scores will be used in ongoing educational activity and feedback to the ES staff following each cycle of evaluation. It is recommended that such results be shared more widely within and beyond the institution as useful and appropriate.
7. Results of the objective monitoring program and interventions to optimize the thoroughness of terminal room cleaning and disinfection will be a standing agenda item for the Infection Control Committee (ICC).

Reporting:

Results should be reported to the ICC and facility leadership and could be reported to the state health department through the state prevention collaborative coordinator by various mechanisms (e.g., NHSN template), depending on infrastructure.

1. Guidelines for Environmental Infection Control in Healthcare Facilities, 2003 [PDF – 1.36MB]
2. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 [PDF – 950 KB]