Healthcare Hygiene magazine March 2020 | Page 16

a wide discrepancy between thoroughness and efficiency. Although a few rooms were fairly well cleaned within 30 minutes (which is an accepted industry benchmark), many of the rooms with below-average cleaning took considerably longer to clean. As Rupp, et al. (2013) explain, “Unexpectedly, there was no correlation between the amount of time spent cleaning a room and the thoroughness of cleaning high-touch surfaces as documented by the UV-tagged marking system. This finding has important implications for institutions that devise strategies to optimize cleaning. Our study lends support to and may explain earlier studies that have shown that improved cleaning performance can be achieved without substantial additional cost. Clearly, adequate time must be allotted for personnel to clean a room properly, but it is apparent that additional time taken to clean a room is no guarantee of adequate cleaning. These data also support additional evaluation to discern whether an optimum outlier (positive deviance) process improvement program could be employed to improve environmental cleanliness. Because several of the environmental service staff in our study appear to be optimum outliers and are able to clean hospital rooms quickly and thoroughly, they may be able to provide personal and programmatic insights to explain their proficiency and serve as models for their coworkers.” The researchers concluded that their findings emphasize that process improvement interventions should evaluate both the efficiency and thoroughness of hospital surface cleaning to optimize the cost effectiveness of cleaning practice in healthcare settings. This study paved the way for follow-up research by Mark Rupp, MD, professor in the Department of Internal Medicine; chief of the Division of Infectious Diseases; and medical director of infection control and epidemiology at the University of Nebraska Medical Center, and colleagues, who conducted a more extensive survey to test the premise that a positive deviance or “optimum outlier” model for improving cleaning might be possible. The researchers sought to ascertain whether a subgroup of housekeepers could be identified as role models in an optimum outlier improvement model. Rupp says this 2014 study confirmed their original observations; however, they were able to document the presence of a small group of housekeepers who perform faster and better than others. Rupp emphasizes that they termed these workers “optimum outliers” (instead of using the term “positive deviance”). “We hypothesized that we could study their habits and procedures and learn,” Rupp says, adding that he’d like to see the term “optimum outlier” achieve more traction within the infection prevention community. The study was conducted in three patient-care units (a burn unit, a telemetry unit, and a medical surgical unit) from April 2011 to August 2011 at a 689-bed academic medical center. Following routine terminal cleaning by EVS personnel, a convenience sample of rooms was assessed during regular work hours by measuring ATP levels on 18 designated surfaces (exterior door handle, bed rail, nurse call button, bedside table, toilet flush handle, bathroom door handle, toilet seat, bedside chair, light switch, mattress, sink 16 Continued from page 15 encouraged higher scoring if turnover times (average set-up and clean-up turnover times for all cases was less than 25 minutes. As Macario (2006) observes, “Most U.S. hospitals perform all cases scheduled by their surgeons, provided a case can be done safely. This reflects the desire to retain and grow surgeons’ practices, to enhance market share and reputation, and to fulfill community-service missions. Getting the right case in the right room at the right time is the goal for every OR director. For anesthesiologists, efforts to increase anesthesia group productivity are the same as increasing the efficiency of use of OR time. Often, though, defining how well the OR suite runs depends on who you ask. The hospital administrator may want the most “throughput” with the least cost, whereas the surgeon wants first case of the day block time, rapid turnover, low cancellation rate, and on-time starts. Nurse managers may focus more on flexibility to move cases around, disposable supply costs/case, the percentage of cases in compliance with flash sterilization policy and having adequate reserve capacity for add-on cases or emergency cases. Risk management, on the other hand, will want to know the percentage of patients without injury (e.g., wrong-side surgery).” “The main challenge of turnover between cases is time, as pressure from both surgeon and administration to begin next case as soon as possible is continually at the forefront,” acknowledges Karen deKay, MSN, RN, CNOR, CIC, perioperative practice specialist at AORN). “However, a clean and safe environment for our patients should be first and foremost. Performing qualitative and quantitative monitoring methods to evaluate the thoroughness of cleaning, as well as a gap analysis to determine compliance with guidelines and policies and procedures can provide documentation of any shortcomings that may be a result of the time pressure. These findings should then be shared with environmental, infection prevention, and perioperative administration for development of an improvement plan that includes continued monitoring.” The great many pieces of equipment and the numer- ous OR personnel rushing around can pose significant challenges to EVS personnel who are trying to follow AORN and AHE guidance on operating suite hygiene. “Irregular surfaces, such as knobs and dials, components of the OR bed specifically beneath the mattresses, and complex pieces of equipment such as a robot, imaging devices and microscope,” deKay says. “Most often, EVS personnel converge all at once to clean/turnover a room and these items may be missed or quickly swiped over. In an organizational experience to improve between case cleaning, Pedereson, et al. found that when a ‘pit crew’ concept was introduced that assigned personnel specific tasks, the overall compliance with cleaning protocol increased from 79 percent to 93 percent. I have also heard of facilities dividing the room into zones and a team captain assigning zones march 2020 • www.healthcarehygienemagazine.com