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In cases where a re-clean and retest approach does not address the problem of continued high RLU values, the following steps in the cleaning process should be evaluated for proper adherence to established policies and procedures.
• EVS staff are properly trained and are following established cleaning protocols Proper use of cleaning chemicals
• Check that the following parameters are in line with manufacturers’
recommendations for use:
– Water Quality – Temperature – Use of appropriate chemistry for the situation being addressed, e.g. use of bleach to address Clostridium difficile – Proper Concentrations/Dilution Ratios are being used – Recommended Contact time/Dwell time is being observed
• Equipment is clean, e.g. buckets and sinks used to mix cleaning solutions are visibly clean
• Appropriate mechanical activity/friction is being applied
• Soil Load/Types of soils – Presence of textured surfaces might contain biofilm and require repeated cleaning with increased mechanical activity to reduce RLU levels – Heavy soil levels might require several cleaning passes before reaching acceptable RLU levels
7. Continuous improvement steps Following initial implementation and corrective action procedures, ongoing review of data should take place to understand whether the process of routine monitoring and corrective action has led to reduced levels of organic contamination either at the test point or unit level.
The percentage of test points with an RLU value ≤ 250 RLU (%Pass) can be used to assess progress when implementing a continuous improvement plan. Successful implementation of improvement initiatives should result in an increase in the % of test points showing RLU values ≤ 250 (increase in %Pass). A reasonable goal would be to have 80% of test points showing ≤ 250 RLU.10 For those high risk areas a higher %Pass (90-100%) should be considered.
Regular, consistent data review is critical to the success of any continuous improvement plan. Data should be reviewed, on an a routine basis, to detect changes in cleaning performance. 3M recommends that a data review take place every 300 samples. As you track performance, a decrease of 10% or greater should trigger an intervention.
Daily review of cleaning performance data is also recommended for spotting those issues that are short-term in nature but also impact overall cleaning performance.
The 3M™ Clean-Trace™ Online Software reports have seven different formats to choose from so that continuous improvement results can be tracked and trended.
The continuous improvement process underpins the ATP hygiene monitoring system and allows the user to review and maintain improved standards of cleanliness in the clinical environment.
Appendix 1 – Test Point Selection and Recommended Sample Plans
Below are lists of example test points that may be considered when setting up a sample plan. The test points selected will ultimately be the choice of the user, and should reflect those areas that are considered as representative information on the efficiency of cleaning procedures carried out. Generally test points will be comprised
of three different types:
1. Direct or close points of patient contact – those areas where there is a higher direct risk of cross contamination to patients and healthcare workers
2. Equipment – equipment that is commonly used and comes into direct contact with patients and staff. This may be equipment that is shared and moved around the hospital or equipment that is dedicated to specific patients
3. General environmental test points – general environmental test points that are not in close proximity to patients but will provide feedback on the general efficacy of cleaning and may present a risk of cross contamination Test Point/High-Risk Area/Equipment Lists These are not exhaustive lists, but serve as a starting point for developing sample plans.
* test point recommendations from the CDC Environmental Checklist for Monitoring Terminal Cleaning a part of the CDC Options for Evaluating Environmental Cleaning Toolkit 3M Recommended Sample Plans Tier 1 – Education and Competency It is recommended that the Sample Plan for Tier 2A be used for assessment of training efficacy and competency testing.
Tier 2B – High risk areas and equipment Sample Plan
1. Overbed Table
2. Patient Room Door Knob (interior)
3. Bathroom toilet flusher handle
4. Remote control/Nurse Call Button
5. Side Bed Rails
7. IV stand – Control Panel
8. Mobile Blood Pressure Cuff
9. Bathroom Grab Bars
10. Patient Toilet Seat References
1. Ruth Carrico, Ph.D., RN, FSHEA, CIC. Environmental Services Infection Prevention and Control Bundle. Clean Spaces Healthy Patients Webinar. January 2012. http:// cleanspaces.site.apic.org/events/tools-and-resources.
2. Boyce, J.M. et al. 2012. Monitoring the Effectiveness of Hospital Cleaning Practices by Use of an Adenosine Triphosphate Bioluminescence Assay. Infect Control Hosp Epidemiol. Vol.30, No. 7 pp. 678-84.
3. Carling, P.C. et al. 2010. Eval hygienic cleaning in health care settings: What you do not know can harm your patients. Am J Infect Control 38:S41-50.
4. Donskey, C., et al. 2012. Daily Disinfection of High-Touch Surfaces in Isolation Rooms to Reduce Contamination of Healthcare Workers’ Hands. Infect Control Hosp Epidemiol. Vol. 33, No. 10 pp. 1039-1042.
5. Otter, J.A. 2011. The Role Played by Contaminated Surfaces in the Transmission of Nosocomial Pathogens. Infect Control Hosp Epidemiol. Vol. 32, No.7, pp. 687-99.
6. Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004.
7. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee. Management of multi-drug-resistant organisms in healthcare settings. 2006. http://www.cdc.gov/ncidod/dhqp/pdf/ar/ mdroGuideline2006.pdf.
8. Dancer, S.J. et al. 2009. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Med Vol. 8 pp. 7-28.
9. Hayden, M.K., et al. 2006 Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures.
Clin Infect Disease. Vol. 42, No. 11 pp. 1552-60.
10. Guh, A., Carling, P.C. and Environmental Evaluation Workgroup. December 2010.
Options for Evaluating Environmental Cleaning http://www.cdc.gov/HAI/toolkits/ Evaluating-Environmental-Cleaning.html.
11. Kelly Pyrek. 2012. Environmental Hygiene: What We Know from Scientific Studies.
Infection Control Today. Vol.16 No.9 pp. 10-32.
12. Eckstein, B.C. et al. 2007. Reduction of Clostridium difficile and vancomycinresistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. Vol. 21. No. 7 p.61.
13. Lewis, T. et al. 2008. A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces. J Hosp Infect. Vol. 69, pp. 156-63.
14. The NYU Langone Medical Center Story. Clean Spaces Healthy Patients http:// cleanspaces.site.apic.org/sucessful-collaborations/nyu-langone-story/.