102


Table 2. Metered Applicator Fluorescent Gel (FG), Cotton Swab FG, and Removal From Bedside Table After Wiping Location


Clare Rock et al


% Person #1 Person #2 Person #3 Person #4 Person #5 Person #6 Person #7 Person #8


Metered applicator FG Dot 1 000100 00 Dot 2 000100 00 Dot 3 100110 00


Cotton swab FG Dot 1 010111 00 Dot 2 010111 00 Dot 3 010111 00 Note. 0=not removed; 1=removed.


Discussion


The CS-FGM product was more frequently removed from HTSs in patient rooms than the MA-FGM product (64.3% vs 60.5%). We hypothesized 2 reasons for this result. First, the CS- FGM product was more visible to the naked eye and was, therefore, preferentially removed. Second, the MA-FGM for- mulation was more adhesive to the HTSs and, therefore, was not as easily removed with wiping. We explored these hypotheses in phase 2 of the study. We found large variability in FGM size for the CS-FGM, demonstrating that dipping a cotton swab into the FG (vs metered applicator) is subjective and dependent on the marker’s approach, even after training in the methodology. The MA-FGM was less easily removed compared with CS-FGM (17% vs 50% removed respectively), possibly related to different gel constituents and resultant adhesiveness. The need for manual pressure to remove biofilm from dry surfaces in the patient environment is increasingly recognized and supports a less easy-to-remove FGM, which is a better surrogate for biofilm removal.4 The CS-FGM lacks standardization and reproducibility and may be a sub- optimal product choice for accountability and performance improvement. We expected a larger difference in removal rate between the


2 products. Potentially, if either FGM was visible, the full HTS was cleaned, thus removing both products. In addition, on some of the small HTSs, there was not have much distance between the 2 FGMs, and both were likely removed simulta- neously. We chose this method of placing the FGM on alter- nating sides of the same HTS rather than each room with a different FGM method, to eliminate confounding due to cleaning practices of the individual environmental cleaning associate.


Removed


13 13 38


50 50 50


Infection control or facilities programs implementing EEC


programs should carefully consider the type and method of appli- cation of FGM to standardize and optimize the measurement of FG removal.


Supplementary material. To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2018.287


Acknowledgments. We thank Dr Philip Carling for providing the fluor- escent gel marker DAZO. Neither Dr Carling nor EcoLab participated in the design, analysis, interpretation, or manuscript preparation of our findings. We thank Verna Scheeler for project coordination.


Financial support. This work was supported by funding from Centers for Disease Control and Prevention (CDC) Epicenters Program (C.R., A.X., Y-J.H., P.O., A.P.G., L.L.M., and S.E.C.)


Conflicts of interest. All authors report no conflicts of interest relevant to this article.


References


1. Han JH, Sullivan N, Leas BF, Pegues DA, Kaczmarek JL, Umscheid CA. Cleaning hospital room surfaces to prevent health care–associated infections. Ann Intern Med 2015;163:598–607.


2. Kenters N, Gottlieb T, Hopman J, et al. An international survey of cleaning and disinfection practices in the healthcare environment. J Hosp Infect 2018. doi: 10.1016/j.jhin.2018.05.008.


3. Options for evaluating environmental cleaning. Toolkits: Preventing HAIs. Centers for Disease Control and Prevention website. http://www.cdc.gov/ hai/toolkits/Evaluating-Environmental-Cleaning.html. Published 2010. Accessed October 13, 2015.


4. Vickery K, Deva A, Jacombs A, Allan J, Valente P, Gosbell IB. Presence of biofilm containing viable multiresistant organisms despite terminal cleaning on clinical surfaces in an intensive care unit. J Hosp Infect 2012;80:52–55.


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