Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 14

Improving hospital staff compliance with environmental cleaning behavior Lilly Ramphal, MD, MPH, Sumhiro Suzuki, PhD, Izah Mercy McCracken, and Amanda Addai, MPH Reducing the incidence of healthcare-associated infections requires proper environmental cleanliness of frequently touched objects within the hospital environment. An intervention was launched in June 2012 and repeated in February 2013 and August 2013 to increase hospital room cleanliness with repeated education and training of nursing and environmental services staff to reduce healthcare-associated infections at Cook Children’s Medical Center. Random rooms were tested, staff were trained about proper cleaning, rooms were retested for surface cleanliness, and preintervention and postintervention values were compared. The percentage of cleaned surfaces improved incrementally between the three trials—with values of 20%, 49%, and 82%—showing that repeat training favorably changed behavior in the staff (P = 0.007). During the study period, during which other infection control interventions were also introduced, there was a decline from 0.27 to 0.21 per 1000 patient days for Clostridium difficile infection, 0.43 to 0.21 per 1000 patient days for ventilator-associated infections, 1.8% to 1.2% for surgical site infections, and 1.2 to 0.7 per 1000 central venous line days for central line–associated bloodstream infections. he Centers for Disease Control and Prevention (CDC) estimated that in 2002, healthcare-associated infections (HAIs) contributed to 1.7 million infections and 99,000 deaths; 33,269 infections were in high-risk newborns, 19,059 in well-baby nurseries, 417,946 among adults and children in intensive care units, and 1,266,851 in adults and children outside of intensive care units. The overall annual direct medical costs of HAIs to US hospitals ranges from a low of $28.4 billion to a high of $45 billion (after adjusting to 2007 dollars using the Consumer Price Index for inpatient hospital services) (1–4). Prevention of HAIs could save an estimated $5.7 to a high of $31.5 billion in inpatient hospital services. For this reason, HAIs have been identified by the US Department of Health and Human Services as a top priority for cost reduction. Over 11,500 healthcare facilities in all 50 states use the CDC’s National Healthcare Safety Network to track HAIs. Thirty states and the District of Columbia require reporting of HAIs using this network (1). The CDC has documented that HAIs are caused by many pathogenic organisms present on floors, bedding, mops, and furniture in the hospital environment (1, 2, 5–8)—what the T 88 CDC has called “high-touch points/objects” (HTOs). Through clinicians’ hands and the environment, patients may be exposed to pathogenic bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and enterococcus (6, 7, 9, 10). Several studies have documented the importance of cleaning and disinfecting and its impact in preventing transmission of pathogens from the environment to providers and patients in a broad range of US healthcare settings (2). This study evaluated whether training interventions would be effective in changing the behavior in nurses and environmental services (EVS) staff in cleaning patient rooms after discharge. Baseline results suggested that several interventions were needed. The ultimate goal was to decrease the rate of HAIs. METHODS This research was considered a quality improvement project and so was exempt from review by the institutional review board at Cook Children’s Hospital. After patients were discharged from their rooms, a public health student entered random rooms on the medical and surgical floors and lightly swabbed HTOs with clear Glo Germ gel before EVS staff or nurses performed routine cleaning duties in each room. The staff was blinded with respect to which rooms were going to be sampled for inclusion in the study. HTOs were marked with a fluorescent marking gel (invisible to the naked eye) evaluated with ultraviolet blue light and then interpreted with Ecolab Recording software after the patients were discharged from the rooms and before the staff came to clean. After the cleaning, the HTOs were evaluated with blue light. If the gel mark was completely wiped off, then the cleaning was recorded as pass. If any surface gel was still present, then the cleaning was recoded as fail. For trial 1, 747 random HTOs were sampled; for trial 2, 1322; and for trial 3, 2188. The percentage of clean surfaces was calculated. This procedure was completed in June 2012, From Cook Children’s Hospital, Fort Worth, Texas (Ramphal); and the Departments of Environmental Health (Ramphal, Addai) and Biostatistics (Suzuki, McCracken), the University of North Texas School of Public Health. Dr. Ramphal is now with Blue Cross Blue Shield. Corresponding author: Lilly Ramphal, MD, MPH, Department of Environmental Health, University of North Texas School of Public Health, 3500 Camp Bowie Boulevard, Fort Worth, TX 76107-2699 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2014;27(2):88–91