Infection Control & Hospital Epidemiology
257
Fig. 1. Overview of the HighlightWipes Lid system. (A) The reusable battery-powered lid attaches directly on top of standard containers of commercially available bleach wipes. A disposable cartridge inserts on top of the reusable lid and contains the Highlight additive, which is administered onto each bleach wipe as it is dispensed. (B) Comparison of visibility of surface coverage 0, 2, and 4 minutes after wiping a bedside rail using bleach wipes alone versus bleach wipes with Highlight.
(Hill-Rom, Chicago, IL), the surface coverage of bleach wipes alone was difficult to see across all time points. In contrast, bleach wipes with Highlight provided a bright blue color that was still visible 2 minutes after wiping but completely faded to clear after 4 minutes. By leaving a blue trace where bleach has been wiped onto a surface, Highlight provides users with a means to monitor their own cleaning technique at the point of use. The fading away of blue indicator after ~4 minutes allows users to monitor the passage of wet-contact time required for bleach wipes. The transient blue color can effectively deter personnel from prema- turely wiping away the bleach, as has been previously reported,5 and it prevents patients and other staff from interacting with recently wiped surfaces that have not reached the necessary contact time. To determine whether Highlight Wipes Lids improve the thoroughness of bleach wipe cleaning over current methods, a prospective study was conducted in a 500-bed academic medical center across 11 medical and intensive care unit (ICU) inpatient wards. Routine terminal cleaning was performed by EVS staff using ready-to-use bleach wipes (Sani-Cloth bleach germicidal disposable wipes, PDI Healthcare, Orangeburg, NY). The staff was then provided with Highlight Wipes Lids to implement in their terminal cleaning. The study was performed over a 55-week period from February 2017 to February 2018. A designated infection control staff member randomly sampled high-touch surfaces following terminal cleaning using an ATP biolumines- cence assay system (SystemSURE Plus ATP Cleaning Verification System; Hygiena, Camarillo, CA). A total of 1,020 high-touch surfaces were sampled, including bedside rails, toilet flush han- dles, room sinks, bathroom door handles, and television remote controls. Based on manufacturer recommendations and institu- tional guidelines, the relative light unit (RLU) benchmarks used to assess thoroughness of cleaning were pass (≤50 RLU) and fail (>50 RLU).8 Cleaning with bleach wipes alone yielded a failure rate of 5.70% (54 of 947 samples) with an average RLU value (mean±SD) of 18±137, whereas the introduction of Highlight with bleach wipes resulted in no failures (0 of 73 samples) with an average RLU value of 14±10. Although the average RLU values for both wiping strategies fell below the cleanliness threshold of 50 RLU, the
high standard deviation for bleach wipes alone indicates that a sig- nificant number of high-touch surfaces were entirely missed from cleaning, resulting in outlier values due to high bioburden. In com- parison, every high-touch surface sampled in rooms cleaned with Highlight passed below the cleanliness threshold of 50 RLU. Our results suggest that the implementation of a real-time
visual feedback system for disinfectant wipes can improve both the thoroughness of surface coverage and cleaning compliance. In fact, a previous study found that the use of Highlight indicator in spray-based bleach disinfectants helped healthcare workers cor- rectly identify surfaces where bleach had been applied.9 We have previously demonstrated that Highlight not only can be added into bleach disinfectants without compromising antimicrobial efficacy and skin safety10 but also acts to reduce bleach corrosion on materials like stainless steel.7 Our study has some limitations. Visibility of the bleach wipe
coverage was only compared on a light surface (bedside rail), although a recent study assessed the blue Highlight indicator on a variety of healthcare surfaces (including black countertops) and found enhanced visibility in most cases.9 In addition, the sample size for bleach wipes with Highlight was small due to the limited scope of the device pilot study in the hospital. None- theless, the perfect pass rate of the high-touch samples cleaned with Highlight as well as the lower and more consistent RLU values suggest that these results are compelling. Additional assessments of this novel cleaning strategy should focus on other metrics including fluorescent marker removal, usability in the hospital setting, healthcare worker feedback, and patient outcomes.
Acknowledgments. We thank Cathy Korn, Mohamed Dassouli, Deborah Gregson, David Maffeo, and all other staff at Boston Medical Center who helped us conduct the hospital study.
Financial support. Kinnos, Inc., provided the product for testing but did not participate in the design or execution of the hospital study.
Conflicts of interest. K.T., K.J., and J.K. are founders and shareholders of Kinnos, Inc., and have patents pending on the Highlight technology.
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