«Hygiene Management System Hygiene Management GuideSurfaces for Environmental Contents Aim 3 Introduction 3 ATP bioluminescent monitoring technology 4 ...»
Hygiene Management System
ATP bioluminescent monitoring technology 4
– What is Adenosine Triphosphate? 4
– The principle of the bioluminescent reaction 4 – Data analysis and reporting 4 3M Recommended Monitoring Plan 5 – 3M Tier 1 Plan – Education and Competency 5 – 3M Tier 2A Plan – Routine Monitoring of the Effectiveness of Terminal Cleaning 7 – 3M Tier 2B Plan – Monitoring High Risk Areas and Equipment 8 Implementation of an ATP Hygiene Monitoring Program 10 – Identification of test points and sample plans 10 – Pass/Fail Threshold Recommendation 11 – Determination of testing frequency 12 – Collection of Data 13 – Establish metrics for each tier implemented 14 – Establishment of corrective action procedures 15 – Continuous improvement steps 16 Appendix 1 – Test Point Selection and Recommended Sample Plans 16 References 19 Surfaces High Touch Monitoring High Tech Aim The Hygiene Management Guide for Environmental Surfaces is a document outlining the steps necessary to set up and implement an effective ATP hygiene monitoring program within a healthcare environment.
Introduction One of the greatest infection risks to a patient entering a healthcare facility is acquiring a pathogen from a prior room occupant who was infected or colonized with a multi-drug resistant organism (MDRO).1 The factors that contribute to this risk are many, some of which are listed below.
• Patients are the largest contributors to pathogens present in the near-patient environment.1
• Compliance to established cleaning protocols can be as low as 50%, leaving behind contaminated surfaces for the next room occupant.2,3
• Hospital rooms and equipment may be complex in design and difficult to clean.
• Pathogens that are not removed or killed during cleaning and disinfection persist on environmental surfaces for weeks to months.5
• Contaminated environmental surfaces are an important source for transmission of healthcare-associated pathogens such as Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE).4
• Healthcare workers can contaminate their hands by touching contaminated surfaces and then transfer pathogens to their patients via touch.4,5 These factors emphasize the importance of environmental cleaning for reducing the spread of infections.4,7,8 There is ample evidence that shows enhanced cleaning of environmental surfaces can lower the infection rates from environmental pathogens.8,9 Because there is an “evolving mandate” that environmental hygiene in healthcare settings be objectively analyzed and optimized, environmental monitoring tools have been developed to assess the effectiveness of cleaning procedures.3,10 ATP bioluminescence monitoring technology The maintenance of a clean environment is an important factor in reducing the risk of cross contamination. Unmonitored, organic residues can build up to high levels on surfaces if adequate cleaning procedures are not adopted. Surfaces, although appearing visibly clean, can still harbor significantly high levels of contamination.
This contamination can provide an ideal environment for the proliferation of microorganisms. In addition, it can provide a resistant barrier against both cleaning and sanitizing agents.
What is Adenosine Triphosphate (ATP)?
ATP is the molecule that provides energy for cellular metabolism and is present in all living cells. Consequently, it is present in any organic residue, e.g. body fluids, skin cells and microorganisms, making ATP an excellent marker for organic contamination or contamination from a biological source.
The principle of bioluminescence reaction
The 3M™ Clean-Trace™ Hygiene Management System is based on the measurement of levels of ATP present on an environmental surface. A 3M™ Clean-Trace™ ATP Surface Test is used to swab a selected test point. The test is then activated and the swab is brought into contact with the test enzyme solution (luciferin-luciferase). The enzyme 4 reacts with any ATP residue present on the swab bud. A product of this reaction is the generation of light by the enzyme solution. The Clean-Trace ATP Surface Test is then placed in the 3M™ Clean-Trace™ NGi Luminometer. This measures the light generated by the enzyme solution and produces a result expressed in Relative Light Units (RLUs).
The greater the level of ATP present on the swab, the greater the amount of light generated by the test and consequently, the higher the RLU level produced. The test can be performed in less than 30 seconds, providing a real-time result that indicates the cleanliness of the surface tested. This provides an opportunity to take any corrective action required such as re-cleaning and re-testing the surface.
Data analysis and reporting
Rapid results allow for corrective action to be taken at the time of testing. Review and trend analysis of collected data is an important part of maintaining and improving hygiene standards on an ongoing basis. To provide a mechanism for reviewing ATP results, the Clean-Trace System includes the 3M™ Clean-Trace™ Online Software, a tool for the capture and auto-analysis of results and auto-generation and delivery of reports. Tracking results over time helps to indicate the effectiveness of cleaning procedures as well as detect any developing adverse trends. The Clean-Trace Online Software provides a range of reports, graphs and hygiene maps to allow easy interpretation and review of results. These can be shared with key hygiene stakeholders at all levels thereby increasing awareness of the state of cleanliness.
3M Recommended Monitoring Plan The Centers for Disease Control and Prevention (CDC) has encouraged hospitals to develop an environmental cleaning and monitoring program to optimize the cleaning of high touch surfaces at terminal cleaning, as well as ensure quality control and improvement.6,7,10 Approaches for optimizing and analyzing the status of environmental hygiene in areas of concern include training/competency evaluation programs and tracking and trending of objective, routine monitoring results as well as risk-based approaches for targeting the most important elements of environmental cleaning and monitoring.2,6,7,10,11,12 What follows in the remainder of this document is the description of a comprehensive monitoring plan that combines recommendations put forth in several pertinent CDC documents and guidelines together with best practices gleaned from successful practitioners of environmental hygiene monitoring. This plan uses a tiered format allowing for the choice of an approach that best fits the immediate needs of your institution while providing a clear path for growing a comprehensive environmental monitoring program.
3M Tier 1 Plan – Education and Competency
It has been shown that positive, supportive educational interventions and regular competency evaluations directed at the Environmental Services (EVS) staff can result in improved decontamination of environmental surfaces.2,3,10,12 Such interventions should include efforts to monitor cleaning and disinfection practices and provide feedback to the EVS staff. The CDC Guidance on MDROs in healthcare settings states
V.B.8.b. Intensify and reinforce training of environmental staff who work in areas targeted for intensified MDRO control and monitor adherence to environmental cleaning policies. Some facilities may choose to assign dedicated staff to targeted patient care areas to enhance consistency of proper environmental cleaning and disinfection services. Category IB7 The more positive training experiences provided for the EVS staff, the more likely they will exhibit the discipline to do the job right and achieve the consistent results needed to maintain good environmental hygiene.
Tier 1 of the 3M Recommended Monitoring Plan focuses on the training and competency of EVS staff, similar to the CDC Options for Evaluating Environmental Cleaning Toolkit Level 1 program.10 There are a number of variables that can affect how well a surface is cleaned. The surface itself, the disinfectant or cleaner that is used, the cleaning protocol followed, and the EVS staff are all known variables in the process. Based on continuing research at 3M, the factor showing the largest variability impacting cleaning effectiveness are the individual EVS staff members (i.e. workerto-worker variability). Therefore, ensuring proper training and on-going competency is the first step in any quality control program. The following steps provide a framework around which a training or competency evaluation program can be built.
1. Identify EVS staff members (and other staff responsible for cleaning equipment) for whom training is required.
2. Identify the surfaces that will be used during training. Five high touch surfaces that encompass the range of surfaces and equipment present in your facility are recommended. (See Appendix 1 for a list of suggested surfaces)
3. Conduct training within a patient room prior to the terminal cleaning.
4. Swab 5 high touch surfaces using 3M™ Clean-Trace™ ATP Surface Tests to measure the ATP levels prior to cleaning the surfaces. Initially, surfaces should have enough organic material to be able to show a difference in RLUs after cleaning.
5. Have the EVS staff member clean the 5 surfaces identified following your facilities policies and procedures.
6 6. Using new Clean-Trace ATP Surface Tests, sample the same 5 high touch surfaces to measure the ATP levels post-cleaning.
7. Repeat sampling of 5 surfaces (before & after cleaning) in an additional 3 rooms to complete the initial testing.
8. Monitor the effectiveness of training over time. 3M recommends that monitoring occur during initial training with follow up at 1 week, 1 month and 3 months for a total of 4 training intervals.
9. Staff should be able to achieve a pass (≤250 RLUs) on 16 out of the 20 touch points (80%Pass). If necessary conduct additional training to improve performance levels.
10. It is recommended that audits be performed at a minimum of every 3 months, increasing to every month as your quality program develops over time.
The Clean-Trace Online Software will enable documentation and trending of both individual and combined staff competency and training results. Several report types are available that can be customized to fit a variety of documentation requirements.
3M Tier 1 Plan – Summary Education and Training + Competency Audit = Total Swabs per Year
Tier 2A – Routine Monitoring of the Effectiveness of Terminal Room Cleaning It is helpful to learn from the successes of colleagues when implementing an environmental monitoring program. Led by Michael Phillips M.D., the “Clean Team” at NYU Langone Medical Center in New York City significantly decreased their Clostridium Difficile rates by employing a creative education program combined with teamwork in implementing an enhanced environmental cleaning program. A critical part of their success was monitoring the efficacy of their cleaning procedures using the Clean-Trace System. Dr. Phillips emphasizes the importance of monitoring cleaning performance as the next step. “We are focused on the daily disinfection of frequently touched surfaces within the patient room.” Phillips explains that “On high-intensity units, this disinfection is conducted twice daily. It is important to assess cleaning and disinfection efficacy.” Phillips further states that, “This data is collected systematically and reported back to our environmental service colleagues – similar to surveillance for surgical site infections or central line associated bacteremia. This type of surveillance is just as important, in our assessment.”11 Similar to the CDC Options for Evaluating Environmental Cleaning Toolkit Level II program, Tier 2A of the 3M Recommended Monitoring Plan focuses on scheduled and objective assessments of terminal room cleaning effectiveness. Using the 3M™ CleanTrace™ Hygiene Management System to develop your monitoring program provides quantitative and objective data to monitor cleaning performance and supports creating a comprehensive quality improvement program.