24 minutes to 47 minutes. For each
housekeeper, the average effectiveness
of cleaning versus the median efficiency
of cleaning was plotted; the researchers
found that housekeepers M, O and Q
cleaned rooms more effectively and
efficiently than did their coworkers.
Housekeeper A cleaned rooms quickly
but was not effective. The researchers
Our study
report that there was no correlation
lends support
between the average effectiveness and
to and may
median efficiency.
Rupp, et al. (2014) note, “From the
explain earlier
viewpoint
of hospital administration,
studies that
there are two major variables to be
have shown
considered in managing the operations
that improved
of EVS. First, cleaning must be effective;
as much as possible, potential patho-
cleaning
gens should be eradicated or removed.
performance
There are increasing data to link
can be achieved
environmental contamination to HAI,
and the first priority should be given to
without
providing patients a safe environment.
substantial
Second, resources are limited, and thus
additional
housekeepers must be encouraged to
maximize efficiency.”
cost. ”
The researchers say their study
— Mark Rupp,
provides insight into optimization
MD
of EVS performance relating to the
measurable values of effectiveness and
efficiency, within the context of employing optimum outlier
models, which previously have been used to improve hand
hygiene compliance.
Where it gets interesting is when variability of cleaning and
disinfection practice is studied. Rupp, et al. (2014) identified
a subset of housekeepers who regularly clean hospital rooms
more effectively and more efficiently than their coworkers.
The researchers say the critical next step is to study the habits
of these optimum outliers and translate the knowledge into
improved practice for all housekeepers.
While the study did not seek to demonstrate an association
between room cleanliness and HAI incidence, it highlights
the importance of understanding the motivations of these
outliers and seeking to replicate their performance across
all member of the EVS team. Equally importantly, this
galvanizing study also continues to encourage dialogue
around room turnover times and taking into consideration
the multiple factors impacting real-world results on the
local level. Although this study may not be generalizable in
all healthcare institutions, Rupp, et al. (2014) explain, “…
three diverse areas of the hospital, including critical care and
routine care units, were studied, and it is likely that other
institutions have similar opportunities to improve effectiveness
and efficiency of cleaning.”
The adequacy of the benchmark cleaning time of 25 to 30
minutes depends on numerous factors such as the presence
of pathogens of concern, suspected/confirmed colonization,
institutional policy, and available resources.
“In general, I think around 30 minutes should be adequate
in most situations,” Rupp says. “However, it also depends
18
on a variety of variables – whether there is equipment in
the room that needs to be cleaned, or are EVS personnel
assigned to clean monitors and keyboards, etc. Also, the
degree of contamination needs to be considered. For
example, a room that housed a longer-term patient who
suffered from fecal incontinence due to C. difficile will
require greater care and a longer period of time to clean
than the room of a short-term patient that was relatively
healthy, not colonized or infected with a multidrug-resistant
organism (MDRO), and who was in the hospital for a short,
elective procedure. I doubt whether most EVS departments
have the sophistication to stratify cleaning needs in many
situations. Many departments probably stratify to some
degree based on the type of unit (for example, rooms in our
ICUs or transplant units require greater cleaning disinfection
procedures and time taken than a routine discharge from
the med/surg ward) and many departments give a bit of
extra time to clean an isolation room.”
The infection prevention community reacted to the
findings of Rupp, et al. (2013) with surprise and dismay,
as it seemingly gave a green light to continue with speedy
turnarounds, since the extra time investment wasn’t
paying dividends.
“That study, along with numerous others, pointed to
the shortcomings and challenges faced by healthcare,
primarily that the healthcare environment is the primary
source of contaminants that contribute to healthcare-related
infections and poor patient outcomes,” says Scherberger.
“This study, and many of the referenced studies virtually
burst the balloon of many healthcare professionals who
believed their ways of doing things were, without question,
‘best practices.’ With balloons burst, others were asking
how to move forward. Many organizations had to take a
step back from their established protocols and silo (sandbox)
mentality and reach out for help. To their great credit, AHE,
APIC and AORN stepped forward to provide vitally needed
education and training.”
Scherberger points to improved education and training
as a response to some of the resulting confusion.
“The AHE now offers formal training to hospital staff
that leads to Certified Environmental Services Technician
(CHEST) and Certified Surgical Cleaning Technician (CSCT)
designations,” he says. “The demand for certified training
opportunities has also seen the rise of certifications from
much of the allied healthcare industry. Many hospitals are
recognizing the importance of certification of their EVS staff
and recognize certificate holders with advancement and
financial reward recognition.”
Supporting better training is improved communication
and collaboration.
“EVS professionals and IPs are collaborating more
than they ever have, for EVS is tasked with maintaining
care environments that are free of environmental surface
contamination and that support safety, service, and efficient
and effective operations,” he says. “IPs have both a vision and
mission to fulfill; their vision is healthcare without infection,
and their mission is to create a safer world through the
prevention of infection. Both disciplines use and promote
tools such as checklists, fluorescent markers, adenosine
triphosphate (ATP) meters, and periodic culture swabbing of
march 2020 • www.healthcarehygienemagazine.com