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GREENING OF HOSPITALS WORKSHOP
Cleaning of Surfaces in Patient Care Areas
Results From New Hospital Studies
Two Paradigm Shifts in Patient Room Cleaning 1st Going from the string mop to the flat mop
system for floor cleaning 2nd Moving from cleaning patient areas with a
detergent + disinfectant to a detergent-free cleaner + bleach
Using Flat (Microfiber) Mopping Systems in Hospitals
Paradigm Shift #1
Take Home Message1. Practical, common-sense
approach for patient care areas, but WILL NOT meet all mopping needs.
2. Immediate water and chemical savings, but most cost savings are a result of reduced labor.
3. Improved ergonomics and cross-contamination infection control
4. Proactively address potential hurdles to implementation.
Mopping Requirements
Patient care areas cleaned daily; common areas cleaned more often
Floor cleaners can contain dangerous chemicals
Special precautions required to avoid cross-contamination
Why Hospitals Switch to Flat Mopping Systems
Ergonomic issues
Labor savings
Reduced chemical and water usage
Cross-contamination concerns related to conventional mopping
What is Microfiber?
Split wedged shape of Polyester fiber
Split wedged shape of Polyester fiber
1/100th of human hair1/100th of human hair
…and what difference does it make for mopping?
Increases the effective surface area of your mop
More effective in cleaning up especially small particles
Microscopic fibers thoroughly clean surfaces
Flat Mopping Systems: How Do They Work?
1. Place
2. Mop
3. Peel
4. Launder
vs. Conventional Loop Mops
1. Dip and Wring
2. Mop
3. Repeat 3x
4. Change Water
5. Send to Industrial
Laundry
Ergonomic Benefits
During use, similar gross motor skills required
Unfavorable positions for both methods, but flat mopping systems significantly reduced the frequency and severity of the risk factors
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project
Ergonomic Analysis
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project
Tasks String Mopping Flat Mopping
Lift empty metal/plastic bucket from cart
Lift metal bucket (5 lbs) Trunk flexion 60°
Lift plastic basin (1 lbs) Trunk flexion neutral
Carry empty bucket/basin and walk 3 feet
Forces at trunk, shoulders, elbow, hands (carrying 5 lbs)
Negligible forces (carrying 1 lb)
Fill and lift bucket/basin
Forces acting on neck, back, hands, wrist, shoulders (water 16 lbs)
Less forces acting due to lower weight (8 lbs)
Lift bucket of water, walk to cart
Flexion of trunk, hips, knees, shoulders. Forces at trunk, wrist, shoulder, elbow
Upper body posture is neutral; less forces acting on trunk, wrist, shoulder, and lower body
Ergonomic Analysis
Tasks String Mopping Flat Mopping
Carry bucket of water, walk to cart
Forces at trunk, wrist, shoulder, and elbow
No longer performed
Lift bucket of water and place on cart surface
Wrist and elbow flexion. Forces acting as previously.
No longer performed
Walk to closet for bottle of cleaning solution on shelf. Reach and grasp.
Neck extension, hips flexion, shoulder flexion 120°
Same
Add cleaning solution and replace bottle on shelf
Neck extension, hips flexion, shoulder flexion 120°
Same
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project
Ergonomic Analysis
Tasks String Mopping Flat Mopping
Pick up wringer and hook it onto lip of bucket
Trunk flexion 80°, elbow flexion 60°, shoulders flexion 80°. Forces acting at trunk.
No longer performed
Push cart to room, distance 25’
Walking with trunk flexion 30°, shoulder and elbow flexion 80°. Forces acting at trunk.
Walking with trunk flexion neutral. Pushing cart with standard equipment.
Remove excess water from mop
Palmar grasp, shoulder elevation and flexion, elbow flexion (using mop wringer)
Wring cloth, wrist/hand twisting with grip force
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project
Ergonomic Analysis
Tasks String Mopping Flat Mopping
Mopping the floor Trunk flexion Trunk flexion
Mopping the floor
Place mop in bucket of water, wring, and continue mopping. Same risks as previous steps
Turn mop head downside up and replace cloth at mop head
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project
Microfiber Considerations
Non-industrial washing machines must be used to wash microfiber mop
heads
Cannot be used in areas contaminated with blood or body fluid
Some products ineffective in greasy, high traffic kitchen areas
Sticky floors?
CA DHS – Licensing and Certification March 2002 Memo:
“…acceptable to install household washing machines to launder
microfiber mops…”
provided: Water Temp between 130 and 140
degrees F Separately from other textiles No bleach/fabric softener
“…as long as (these conditions) are met, there should be no infection control related issues.”
Not All Mopping Systems are Created Equal…
No governing body or industry definition of “microfiber”
Density of fibers per square inch can affect pricing and cleaning ability
…vs denier (diameter of fiber)
Some are pretreated with antimicrobials
Should I Use Disinfectants for Cleaning Floors?
Some microfiber products are treated with triclosan or other antimicrobials
Concerns about general use of antimicrobials
Potential for causing antimicrobial resistance
Unknown long term consequences of its use
How many mops handles/heads needed?
Mop Handles = Number of Janitors
Mops Heads =
+twice the number of rooms cleaned daily
+“shrinkage”
+special circumstance – large rooms, extra dirty rooms
Case Study: University of California Davis Medical Center
Reasons for change…
Increase in worker’s compensation claims
Frequent “light duty” ergonomic requirements
Reduce cleaning time for patient rooms
Reduce chemical use and disposal
Cost Analysis: Lifetime Mop Costs
Conventional Wet Loop Mops
$5 each
55 to 200 washing lifetime
22 rooms cleaned per washing
$0.11 to $0.41 per 100 rooms
$4.00 each
500 to 1,000 washing lifetime
1 room cleaned per washing
$0.40 to $0.80 per 100 rooms
Microfiber Mops
Cost Analysis: Chemical Costs
Conventional Wet Loop Mops
10.5 ounces per day
$0.22 per ounce
20 rooms cleaned per day
$11.55 in chemicals per 100 rooms
0.5 ounces per day
$0.22 per ounce
22 rooms cleaned per day
$0.50 in chemicals per 100 rooms
Microfiber Mops
Cost Analysis: Water Use
Conventional Wet Loop Mops
21 gallons per day
20 rooms cleaned per day
105 gallons of water used per 100 rooms
1 gallon per day
22 rooms cleaned per day
5 gallons of water used per 100
rooms
Microfiber Mops
Cost Analysis: Labor Costs
Conventional Wet Loop Mops
20 rooms cleaned per 8 hour shift
$12 per hour
$480 per 100 rooms
22 rooms cleaned per 8 hour shift
$12 per hour
$436 per 100 rooms
Microfiber Mops
Flat Mopping Systems Performance Summary
Microfiber last 5 to 10 times longer
Increase production by 10%
Use 95% less chemical
(2.5 vs. 53 ounces per 100 rooms cleaned)
Use 95% less water
(5 gals vs. 105 gals per 100 rooms cleaned)
Overall costs about 5-10% less - not including workers comp savings
Costs/Benefits That Are Not Quantified Reduced risk of
cross-contamination related to mopping
Reduced worker’s compensation claims
Reduced water use
Patients say: “quieter, quicker, less disruptive”
Discussion
1. Who’s currently using microfiber mops?
2. How satisfied are you with them in patient care areas?
3. What hurdles did you have to overcome?
4. What have you seen as the greatest benefit to using microfiber mops?
Take Home Message1. Practical, common-sense approach
for patient care areas, but WILL NOT meet all mopping needs.
2. Immediate water and chemical savings, but most cost savings are a result of reduced labor.
3. Improved ergonomics and cross-contamination infection control
4. Proactively address potential hurdles to implementation.
Resources
EPA Factsheethttp://www.epa.gov/region/waste/p2/projects/hospital/mops.pdf
Sustainable Hospitals 10 reasons to use microfiber mops
http://www.sustainablehospitals.org/PDF/tenreasonsmop.pdf
Practice Greenhealth http://www.h2e-online.org/docs/h2emicrofibermops.pdf
The Need for Action
The number of Healthcare Acquired Infections is too high
Even with interventions: Hand hygiene education Gel stations installed throughout patient care areas Closer oversight of drug administration
HAIs and associated deaths continue Cost of a patient room runs $9,462 per day
Unnecessary Deaths: The Human and Financial Cost of Hospital Infections
By Betsy McCaughey, Ph.D. HAIs are the fourth largest killer in America HAIs add an estimated $30.5 Billion to the cost of
healthcare in the US each year There is compelling evidence that nearly all
HAIs are preventable This creates a new legal issue
Estimated Hospital Cost of HAIs
2,000,000 Estimated HAIs per year in USA
X
$15,275.69 Average additional hospital costs per HAI
= $30.5 Billion Per year treating HAIs
Cleaning is Essential Cleaning hands is the first step – preventing
recontamination is the second Two studies showed that over half of objects
that should have been cleaned or disinfected were overlooked
As long as surfaces in a hospital are not cleaned, caregivers’ hands will be recontaminated
Cleaning of Environmental Surfaces is Essential
Cleaning of environmental surfaces is so important that if not done properly, the placing of a patient into a room previously occupied by a patient with C-diff can be a fatal error
Studies of Patient Room Cleaning Studies undertaken by HospAA of two-step
cleaning process Studies measured the current cleaning prior
to implementing the two-step cleaning process Current process used cleaners with quaternary
ammonium disinfectant This process leaves a residue that can lead to a
biofilm
Paradigm Shift #2 Two-Step
Cleaning First step: Clean to remove biofilm with non-detergent cleaner that contains 218 ppm bleach Sodium Chloride is used to soften water Sodium Citrate is used to chelate hard water mineral
deposits Sodium Carbonate is used to saponafy organic soils into
soaps that are easily rinsed Sodium Bicarbonate is used as a builder and sequester
Second step: Wipe the 14 HROs with bleach of 1,000 ppm
How Detergent-Free Cleaners Work
Cleaning is defined as: the ability to clean or remove soil from a surface
Accomplished by one or more of the following Lowering surface and interfacial tensions Solubilization of soils Emulsification of soils Suspension of removed soils Saponification of fatty soils Inactivation of water hardness Neutralization of acid soils
Background for Studies
Used luminometers manufactured by 3M to measure adenosine triphosphate (ATP)
ATP measured in relative light units (RLUs) The 14 high risk objects (HROs) outlined by
Dr. Philip Carling in his studies were measured
ATP Luminometer
Carling’s 14 High Risk Objects Objects:
Sink Toilet Seats Over Bed Tray Bed Side Table Toilet Handle Bed Side Rail Nurse Call Box
Visitor Chair Arm Rest Patient Telephone Rest Room Door Knob Restroom Hand Rail Bedpan Cleaner Patient Room Door Knob Restroom Light Switch
Using the ATP Swab
Results of Studies Three hospitals: Tested a minimum of 25 terminally
cleaned rooms in Phase I 1,011 measurements made of the 14 HROs
Mean Measurement was 441 RLU Worst HROs:
Nurse Call Box 900 RLU (N=75) Patient Telephone 742 RLU (N=68) Visitor Chair Arm Rest 624 RLU (N=75) Bedside Rail 503 (N=77) Rest Room Door Knob 489 RLU (N=53) Sink/Counter 445 RLU (N=79) Rest Room Hand Rail 411 RLU (N=76)
Efforts to Standardize Studies Attempted to measure a minimum of 25
terminally cleaned rooms in each phase No disturbance of patients The room was ready for re-occupancy
Trained staff doing ATP measurements Uniformity in swabbing Focused on the worst of Dr. Philip Carling’s 14
HROs Sampled with staff and monitored results
Results From Four Hospitals Phase I (cleaner/quaternary ammonium
disinfectant) (N= 408) Worst Five measured at each facility Mean 1,360 RLU (r=468 RLUs – 2,290 RLUs)
Phase II (DFC + bleach) (N= 412) Mean 143 RLU (r=89 RLUs – 199 RLUs)
Four Hospital Study Results
HRO RLUs Before* RLUs After*
(Phase I) (Phase II)
Restroom Door Knob 1,934 89
Nurses Call Box 2,290 143
Patient Telephone 1,126 104
Bed Side Rail 983 164
Visitor Chair Arm Rest 1,045 199
Restroom Hand Rail 486 143
Sink/Counter 468 127
* These are Mean scores in RLUs
Four Hospital Cleaning Study
0
500
1,000
1,500
2,000
2,500
NURSE CALL BOX VISITOR CHAIR ARMREST
PATIENT TELEPHONE BED SIDE RAIL RESTROOM HANDRAIL
RESTROOM DOORKNOB
SINK/COUNTER
High Risk Objects (HROs)
Rel
ativ
e L
igh
t U
nit
s (R
LU
s)
Prior Cleaning
Two-step Cleaning
Percent of Samples Found “Clean” A surface is deemed to be clean at a reading
of 250 RLU or less using the 3M luminometer Results from the four hospital studies:
Phase I: Found 25.0% were below 250 RLU Phase II: Found 87.4% below 250 RLU
Four Hospital Cleaning Study
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
<250 RLUs 250 - 499 RLUs 500 - 999 RLUs ≥1,000 RLUs
Relative Light Units (RLUs)
Per
cen
t
Prior Cleaning
Two-Step Cleaning
Future Patient Rooms
Continuous Improvement
Train EVS staff in use of DFC + bleach Use ATP monitoring to measure change Continue use of ATP monitoring for training
and quality assurance Monitor HAIs Develop a Process Improvement Story