INFECTION CONTROL
“Testing for bacteria takes days – it only measures bacteria and tells you nothing about the presence of soil in which the bacteria are transported, deposited and reside. Ultimately, effective cleaning removes soil and bacteria so disinfectants can work properly. Objective measurement is the catalyst for change; it improves communication, understanding, restores pride and ownership, and enables behaviour change.”
Productivity and cost benefits He pointed out that there are also benefits to be gained in terms of productivity and achieving value for money. Only 40% of hospitals are cleaned according to policy, so 60% of the cleaning budget is effectively being wasted. He explained that there is a significant productivity dividend (valued at $300m) to be gained from effective management of cleaning, which costs the UK over £500m per annum. Continued improvement of cleaning is also associated with lower infection rates, which are a significant cost burden to Trusts (each infection costs £4k - £10k+). North Tees and Hartlepool Trust, for example, has been championing the use of ATP technology for nearly a decade, and has reduced ATP average scores, which in turn has helped to reduce infection rates through improved cleaning – along with a host of other infection prevention interventions.
Integrated approach The symposium highlighted the superiority of quantitative testing over subjective visual inspection. However, a recent paper by Whitely et al (2015)15 developed this further by considering the various strengths and weaknesses of a variety of different monitoring methods – including visual inspection, microbial recovery, fluorescent marker assessment and rapid ATP bioluminometry. The authors highlighted the ‘failure risks’ associated with each of the approaches, pointing out that each monitoring method generates different types of information. Visual inspection was associated with the highest risk of failure; however, the authors suggested that an alternative method, such as ATP, could mitigate the risk rating. The use of a rapid method such as ATP, which takes around 15 seconds, could also address issues around delays in obtaining microbial results.
The authors further suggested that the
use of ATP could be supported through concurrent use of fluorescent marker or microbial recovery (during any outbreak of disease), along with training, to mitigate risk. Ultimately, the authors concluded that the strengths of each
24 THE CLINICAL SERVICES JOURNAL
approach can compensate for the weaknesses in others. Therefore, the approaches work best in combination. Commenting on the paper, Martin Easter said: “The ATP test is not a replacement for a bacteria test. However, there is a direct and concurrent relationship between ATP and bacterial contamination. Effective cleaning simultaneously removes both organic soiling and bacteria such that the percentage of ATP failures increases as bacterial contamination increases.”10,16 He concluded that ATP can complement the use of microbial testing and fluorescent UV marking, as part of an overall integrated approach to improvement – Leeds Teaching Hospitals NHS Trust, for example, is using Hygiena’s technology as part of a three part process that draws on visual, ATP and UV monitoring. However, the fluorescent marker method is primarily a qualitative auditing and training tool, whereas the ATP method is an independent, quantitative monitoring tool. It can have many applications, including training, investigative and monitoring. “Ultimately, cleaning is a fundamental principle that provides the keystone that binds the elements of infection prevention and control together. Effective cleaning produces a safe, pleasant environment for patients, clinicians and healthcare workers. Maintaining a good environment reinforces and encourages good, safe practices.” ✚
References 1 Hayden, M, et al, Reduction in Acquisition of Vancomycin-Resistant Enterococcus after Enforcement of Routine Environmental Cleaning Measures, Clinical Infectious Diseases 2006; 42:1552–60, accessed at:
http://cid.oxfordjournals.org/content/ 42/11/1552.full.pdf
2 Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. Am J Infect Control. 2010 Jun;38 (5 Suppl 1):S41-50. doi: 10.1016/j.ajic.2010.03.004.
3 BSI, PAS 5748 Specification for the planning, application and measurement of cleanliness services in hospitals. Accessed at:
www.bsigroup.co.uk
4 Harrington, H. James, Poor-Quality Costs, 1987, American Society for Quality.
5 Galvin, S, et al, Microbial monitoring of the hospital environment: why and how? Journal of Hospital Infection 82 (2012) 143e151
6 Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol, 2011; 32: 687–99.
7 Hardy, KJ, et al, A Study of the Relationship Between Environmental Contamination with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Patients’ Acquisition of MRSA, Infection Control and Hospital
Epidemiology, 2006;27:127–132
8 Drees M, Snydman D, Schmid C, Barefoot L, Hansjosten K, Vue PM, et al, Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci. Clin Infect Dis, 2008; 46: 678–85.
9 Griffith, C J, The Royal Society for Public Health (RSPH), 2010.
10 Griffith, C J, Obee P, Cooper, R A, Burton, N F, Lewis, M, Evaluating the thoroughness of environmental cleaning in hospitals. Journal of Hospital Infection 01/2008; 67(4):390.
11 Epic 2 Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals, accessed at
http://www.his.org.uk/files/ 3813/7088/0820/4_epic2_National_ Evidence_Based_Guidelines_for_Preventing_ Healthcare_Associated_Infections_in_NHS_ Hospitals_in_England_2007.pdf
12 Griffith C J, Handbook of Hygiene Control, 2005
13 Hay, A, Audit in infection control, Journal of Hospital Infection, March 2006, Volume 62, Issue 3, Pages 270–277
14 Griffith CJ, Cooper RA, Gilmore J, Davies C, Lewis M. An evaluation of hospital cleaning regimes and standards. Journal of Hospital Infection, 2000;45:19e28.
15 Whiteley G, Derry C, Glasbey T, Failure analysis in the identification of synergies between cleaning monitoring methods, American Journal of Infection Control 43 (2015) 147-53
16 Mulvey, D, et al, Finding a benchmark for monitoring hospital cleanliness, Journal of Hospital Infection, January 2011 Volume 77, Issue 1, Pages 25–30, DOI:
http://dx.doi.org/10.1016/j.jhin.2010.08.006
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