Environmental Monitoring in Healthcare to Ensure Adequacy of Housekeeping Cleaning and Reduce the Spread of Hospital Acquired Infections (HAIs)

Hospital acquired infection (HAI) rates create a significant burden on the healthcare system in terms of morbidity and mortality for affected patients as well as from a financial perspective for the healthcare facility (Action plan USA, Best Practices PIDAC 2012, Carling 2010). The current HAI rates have been deemed unacceptable and the need to reduce these HAI rates has become an urgent priority in the USA as reflected in the Dept. of Health and Human Services Action Plan.

Acquisition of HAIs may arise from the patient's "endogenous" microorganisms and be related to the patient's underlying co-morbidities or they can arise from exposure to microorganisms derived from environmental reservoirs. The percentage of HAIs due to environmental "exogenous" sources versus the patients' own "endogenous" sources cannot be clearly defined. However, the role of the environment as a reservoir for pathogens that contributes to HAI rates has been well documented as patients admitted to healthcare rooms that previously contained patients with MRSA, VRE or C.difficile have a higher risk of acquiring these same AROs despite the fact that the room had been cleaned (Best Practices 2012, Carling 2010, Drees 2006, Hardy 2006, Martinez 2003, Shaughnessy 2011). Although the exact number of HAIs acquired from environmental reservoirs is not known, recent modeling of C.difficile transmission in healthcare estimated that improving hygiene and sanitation could provide a ten-fold reduction in C.difficile HAIs (Yakob et al 2013).

The role of the environment in transmission of pathogens varies depending on the specific pathogen's route of transmission, infectious dose and ability to survive in the environment.

It is difficult, if not impossible, to completely eradicate endogenous infection risk, however the presence of environmental reservoirs of microorganisms is something that should be controlled and eradicated by adequate housekeeping. But how does one know for sure the surface cleaning has been adequate? Although visual inspection of healthcare rooms after cleaning has been used for years, it is now apparent that this is an inadequate way to monitor housekeeping cleaning (Best Practices 2012, Cooper 2007, Malik 2003, Sherlock 2009). Current guidelines (Best Practices 2012) recommend that monitoring of housekeeping should be done to ensure that compliance with cleaning is adequate. There are numerous reports relating to the use of ATP, UV marker and viable counts to assess both environmental and medical device cleaning compliance in health care (Aiken 2011, Alfa 2013a,b, Ali 2012, Anderson 2009, Anderson 2011, Aycicek 2006, Boyce 2009, 2010, 2011, Cooper 2007, Dancer 2011, Fushimi 2013, Griffith 2007, Havill 2011, Kim 2011, Lewis 2008, Malik 2003, Moore 2010, Mulvey 2011, Obee 2005, Sciortino 2012,Shama 2013,Sherlock 2009, Tratjman 2013,Wilson 2011, Wren 2008)

However, there is an absence of evidence regarding the impact of monitoring housekeeping cleaning compliance using ATP, UV marker, or cfu/cm2 on reducing HAI rates. This has led to confusion as to the best way to eliminate these environmental reservoirs in healthcare. Historically the use of disinfectants in healthcare had been thought not to be necessary providing adequate cleaning friction was used. Recently this view has changed and some guidelines for environmental cleaning in healthcare recommend that disinfectants that kill environmental microbes, not just cleaning agents, be used (Best practices 2012). Indeed for patients on isolation precautions heightened environmental cleaning frequency has been recommended if ongoing transmission of microorganisms such as C.difficile is detected (Best practices 2012). There is also confusion regarding what single monitoring method or combination of methods provides the best optimal approach that will reduce HAI rates.

Currently data confirms that acquisition of HAIs from environmental reservoirs can cause significant patient harm in the form of increased morbidity and mortality (Carling 2010, Shaughnessy 2011, Action Plan 2009, Best Practices 2012, Dancer 2011, Drees 2008, Hardy 2006, Martinez 2003). There is an absence of evidence to clearly determine if monitoring of housekeeping cleaning compliance can reduce acquisition of HAIs that arise from environmental reservoirs (i.e. if cleaning compliance of housekeepers is high will this reduce the rates of HAIs in healthcare?). Another area of absence of evidence is whether the monitoring method (e.g. UV marker, ATP, viable count) used affects the possible HAI rate reductions that can be achieved (i.e. if you use ATP to monitor and ensure cleaning to that benchmark does the HAI reduction differ when UV marker benchmarks are used?). Furthermore, there is confusion in healthcare regarding what the appropriate benchmark is for environmental surfaces that indicates adequate cleaning has been achieved (ie. what level of residual RLUs, UV marker or cfu/cm2 is acceptable?).

This results in suboptimal integration of the utilization of cleaning monitors to assess housekeeping cleaning compliance in healthcare facilities.

This issue of poor integration of the use of cleaning monitors applies to both internal facility-based housekeepers and third party housekeepers.

The use of cleaning monitors has a cost to the healthcare system that depends on the monitoring method used and the staffing time required to perform and track the audit results. In order to optimize the value of this cost within the healthcare system it is critical to provide evidence that the effort in monitoring cleaning compliance is warranted because it ensures reduced HAI rates.

Currently there is an absence of evidence to guide healthcare facilities as to how best to use monitoring methods to improve environmental cleaning compliance and thereby reduce HAIs. The opportunity to reduce harm to patients by effective implementation of environmental cleaning monitoring is being missed because healthcare facilities are concerned about the cost, are confused about optimal integration, and do not recognize the patient-care related value of this approach. If a White Paper was developed based on this topic, it would help identify the gaps in knowledge regarding; the impact of cleaning monitoring on HAI rates, the best monitoring approach (or combination of approaches) to use (i.e. ATP vs UV marker vs viable count (cfu/cm2), as well as the need for, and type of disinfectant to use to ensure minimal risk of environment derived HAIs.

The White Paper recommendations can direct future research needs to ensure the data published provides an evidence-based approach for guidelines to use in their recommendations for monitoring healthcare cleaning, and reducing the spread of HAIs. The 3M Hospital Hygiene Global Advisory Board is comprised of the world's key opinion leaders and as such the support of the White Paper recommendations by the committee members in various countries, at various professional conferences and on various guideline committees will facilitate extensive integration.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

I am a Clinical Microbiologist with FCCM certification and currently the Medical Director for Clinical Microbiology within Diagnostic Services Manitoba, Canada. I am also a Professor in the Dept of Medical Microbiology at the University of Manitoba and a Principle Investigator at the St. Boniface Research Centre studying Hospital Acquired Infections due to inadequate cleaning of medical devices and/or the environment. In particular my research has targeted interventions to reduce the spread of C. difficile spores within the healthcare environment. Integration of research findings that demonstrate effective methods of reducing HAIs into routine healthcare practices is currently one of my primary objectives. I have previously participated as a committee member and continue to contribute to Canadian, American and International Guideline development agencies (e.g. AAMI, CSA, CHICA, ISO). (Note: currently I am an active committee member of the CSA).

If you are you making a suggestion on behalf of an organization, please state the name of the organization

I am making this topic suggestion on behalf of the 3M Hospital Hygiene Global Advisory Board.

Please tell us how you heard about the Effective Health Care Program

I have read several of the White papers prepared by this group and also was aware of the AHRQ website.