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E vidence has shown that the hospital environment plays a significant role in the transmission of pathogens, many of which are

responsible for health care-associated infections (HAIs).1 Contaminated surfaces and equipment in the OR can harbor a range of bacterial pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile (C. diff), all of which possess unique characteristics that can make them difficult to eradicate from the environment.1

Some environmental bacteria have exceptional survival rates—VRE can remain viable on dry surfaces for almost four years;1 coagulase-negative staphylococci can colonize patients several weeks after source patients are discharged;2 and C. diff spores are highly resistant to drying, heat, and chemical and physical agents.3 Despite the resilience of these pathogens, improved environmental cleaning and disinfection, in combination with hand hygiene, has proven effective at reducing their spread.3 However, recent evidence has demonstrated a lack of thoroughness in OR environmental cleaning, in addition to noncompliance with environmental cleaning policies and recommended practices.2

Addressing variance in cleaning practicesA growing body of evidence has revealed

opportunities to improve the thoroughness of environmental cleaning practices. According to a study involving 71 ORs, only 25 percent of surfaces were cleaned thoroughly.2 In a study of 40 critical care rooms, the overall thoroughness of cleaning

was 41 percent, with thoroughness ranging from 5 to 79 percent for different high-touch surfaces.4 “Approximately 30 to 50 percent of what should be cleaned per policy is being cleaned by the environmental services staff unless they have a program for improvement,” said Phil Carling, MD, Boston University School of Medicine.

Evidence has also shown the need for improved compliance with recommended hand hygiene practices. An estimated 20 to 40 percent of HAIs have been attributed to cross infection via the contaminated hands of health care personnel who have had direct patient contact or contact with contaminated environmental surfaces.3 In addition, evidence has shown that health care personnel are less compliant with hand hygiene practices after they have had contact with the environment than after direct patient contact,5 although hand or glove contamination with certain pathogens poses approximately the same risk for contact with environmental surfaces as compared to direct contact with an infected or colonized patient.1

Interventions for cleaning process improvementThe wide variation in environmental cleaning

processes demonstrates the need for improved compliance. Health care personnel should take action to verify that between-case and terminal room cleaning practices are performed by environmental services (EVS) workers in compliance with recommended practices set forth by organizations like AORN and the Centers for Disease Control and Prevention (CDC). AORN’s “Recommended practices for environmental cleaning”6 provide comprehensive guidance on environmental cleaning considerations for a safe

Evaluating and improving cleaning practices in the ORLeslie KnudsonManaging Editor

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environment of care, prevention of transmissible infections, and hand hygiene. The CDC and the Healthcare Infection Control Practices Advisory Committee “Guidelines for environmental infection control in health care facilities”7 provide strategies for cleaning and disinfecting surfaces in patient-care areas and emphasize hand hygiene and enhanced cleaning for high-touch surfaces.

Evaluating and monitoring techniquesThe CDC provides specific guidance for

evaluating environmental cleaning and outlines two programs for hospitals looking to implement objective monitoring. The Level I program includes the formation of a hospital-specific infection prevention and control program, defined cleaning responsibilities, structured EVS staff education, development of monitoring measures, and interventions to optimize the thoroughness of terminal room cleaning and disinfection.8 The Level II program includes the Level I elements, plus an objective assessment of the thoroughness of room surface disinfection cleaning and scheduled ongoing monitoring of thoroughness of disinfection cleaning, with results incorporated into educational activity and staff feedback.8

Although there is no standard method for measuring surface cleanliness, a variety of monitoring techniques exist to help objectively assess cleaning practices and monitor improvement. Surface cultures, detection of adenosine triphosphate (ATP), and use of florescent marking have all been used in environmental cleaning validation processes.4 Studies have shown the combination of a fluorescent gel marking system with environmental cultures and the use of a transparent disclosing agent with UV light have played an integral role in improving disinfection cleaning processes.2,9

Performance feedback and educationAlthough objective methods can help evaluate

cleanliness and identify opportunities for improving cleaning thoroughness, high compliance rates can be achieved and maintained with ongoing structured education and feedback programs for EVS staff members and other health care personnel. “There needs to be more consistency and recognition of the CDC’s recommendations, but many hospitals are moving to structured programs, objective feedback, and are seeing surprisingly good results as soon as the cleaning staff is educated and are provided feedback on a

regular basis,” said Carling. One study showed the development of a structured education and feedback program based on the results of fluorescent dye marking and environmental cultures translated to an 87 percent improvement in cleaning thoroughness.9 Intervention programs that involve EVS personnel in education, monitoring, and performance feedback have resulted in significant improvement in cleaning practices.10

Additional considerations for augmenting cleaningEvidence highlights the importance of cleaning

environmental surfaces in rooms where colonized or infected patients received care. “Prior-room occupancy” studies show there is increased risk for a patient to acquire a pathogen (e.g., C. diff, MRSA, VRE, Acinetobacter baumannii) if the previous room occupant was an infected or colonized patient.1 Efforts should be made to reduce and contain the shedding of pathogens through rapid identification and isolation of infected or colonized patients, improved terminal room cleaning and disinfection, and source control strategies.1

New non-touch cleaning and disinfection technologies, such as hydrogen peroxide vapor and ultraviolet irradiation, are being used by some hospitals to help decontaminate environmental surfaces and augment their between-procedure and end-of-day cleaning.10 Although some technologies have shown promise for helping to decontaminate environmental surfaces and objects, additional clinical studies are needed to determine their benefits and recommended usage in comparison to standard cleaning and disinfection processes.

ConclusionAs evidence has confirmed that contaminated

environmental surfaces contribute to pathogen transmission, more needs to be done to improve the thoroughness of environmental cleaning and disinfection practices. Strategies to improve cleaning thoroughness and achieve compliance with environmental cleaning practices should include the implementation of cleaning and disinfection policies, objective evaluation and ongoing monitoring of surface cleanliness, structured educational activities, and objective performance feedback to EVS staff members. In addition, programs should emphasize the critical role of hand hygiene and EVS staff members in closing the infection control loop. Through targeted intervention efforts, ample opportunity exists to improve environmental

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cleaning and disinfection processes and sustain those improvements for optimal environmental hygiene and safe patient care.

References1. 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(5 Suppl):S6-S11.

2. Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93(3):358-364.

3. Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control. 2010;38(5 Suppl 1):S25-33.

4. Rupp ME, Adler A, Schellen M, et al. The time spent cleaning a hospital room does not correlate with the thoroughness of cleaning. Infect Control Hosp Epidemiol. 2013;34(1):100-102.

5. Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital

hand hygiene compliance. J Hosp Infect. 2010;76(3):252-255.

6. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014.

7. Sehulster LM, Chinn RYW, Arduino MJ, et al. Guidelines for environmental infection control in healthcare facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004.

8. Options for evaluating environmental cleaning. Centers for Disease Control and Prevention. http://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html. Published December 2010. Accessed February 4, 2014.

9. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904.

10. Rutala WA, Weber DJ. Disinfectants used for environmental disinfection and new room decontamination technology. Am J Infect Control. 2013;41(5 Suppl):S36-41.

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