environmental hygiene
By Linda Homan , RN , BSN , CIC
Three New Studies Evaluate the Impact of Environmental Hygiene Strategies on HAI Reduction
In today ’ s environment of limited budget and staffing resources for environmental hygiene , it is more important than ever to weigh the evidence before investing in a product , process or technology . Evaluating the clinical impact of environmental cleaning and disinfection products , processes and technologies remains challenging .
In 2013 , leaders at the Division of Healthcare Quality Promotion of the Centers for Disease Control and Prevention ( CDC ) published an article that outlined the hierarchy of evidence needed to advance the science of environmental hygiene and improve patient safety . 1 The hierarchy of study design for increasing patient safety through healthcare environmental surface cleaning and disinfection , listed from lowest to highest strength of evidence is as follows :
I . Laboratory demonstration of bioburden reduction efficacy ( 10 3 -10 6 log reductions depending on the claims ).
• Data that must be submitted to the Environmental Protection Agency ( EPA ) to prove efficacy of a product .
II . Demonstrate in-use bioburden reduction .
• Evidence that use of a product , process or technology reduces bioburden on surfaces in a clinical setting .
III . Demonstrate that in-use bioburden reduction may be clinically relevant .
• Terminal-only use : Reduction of same room transmission
• Terminal and daily use : Reduction of hand contamination
IV . Demonstrate reduced pathogen transmission via admission-discharge active surveillance testing or clinical incidence .
• Evidence that patients do not become colonized with pathogens during their healthcare stay .
V . Demonstrate reduced infections .
• Evidence that the product , process or technology reduces patient infections - the ultimate goal of environmental hygiene .
The authors point out that , for studies to reach the rigor required for levels III-V , careful attention must be paid to baseline infection rates , trends , patient population and sample size . Level III-V studies must also control for other key infection prevention interventions such as hand hygiene , source control / isolation practices , device / procedure-specific interventions and antibiotic use , as these variables can influence the patient outcome .
In the past decade , the body of evidence supporting the role of environmental hygiene in infection prevention has grown
significantly . However , the most important evidence ( Level V ) demonstrating that a product , process or technology decreases healthcare-associated infections ( HAI ), has been slower in coming . This is at least in part due to the rigor that is required to measure this outcome .
Three recent studies evaluated the efficacy of different environmental hygiene strategies on HAI reduction : 1 ) monitoring and feedback of environmental cleaning using a made-for-purpose fluorescent marker , 2 ) implementing a comprehensive environmental hygiene program , and 3 ) the use of UV-C disinfection upon patient discharge or transfer .
Read on to find out which of these interventions were found to decrease HAIs and which were not .
Optimized Process : Environmental Hygiene Monitoring and Feedback
The CDC , as well as professional associations such as the Association for the Healthcare Environment ( AHE ), the Association of periOperative Registered Nurses ( AORN ), and the Association for Professionals in Infection Control and Epidemiology ( APIC ), recommend the use of an objective environmental hygiene monitoring method , along with direct observation , to ensure that high-touch objects are consistently and thoroughly cleaned .
A new study published in July 2022 reports on 10 years of retrospective data on the impact of a monitoring and feedback program using a made-for-purpose fluorescent marker to improve the thoroughness of cleaning in multiple hospital units . 2 The author found that the use of a fluorescent marker improved and ultimately sustained thoroughness of cleaning over the course of a decade . The initiative started with patient room discharge cleaning and expanded into operating room , cardiac cath lab , labor and delivery and endoscopy suites over time . Over time , and with consistent effort , thoroughness of cleaning improved to meet target goals and was sustained over several years . A key strategy was the use of nurse liaisons who , along with other infection prevention initiatives , were trained to conduct environmental hygiene monitoring and provide feedback to environmental services ( EVS ) staff and leadership . The value of this approach was reinforced as they found that , during periods when EVS was self-monitoring , the cleaning results were falsely higher than cleaning scores as validated by an objective third party .
Most importantly , the author reported that improvements in cleaning and disinfecting performance throughout the hospital over a 10-year period were associated with infection reduction : A 75 percent overall reduction in HAI rates , including a 55 percent reduction in surgical site infection rates and a 70 percent reduction in hospital-acquired C . difficile infection rates . As mentioned above , for a Level V study , controlling for variables that may impact the infection rates is important . This study was