Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives | Page 16

in one of three different forms: increasing the
daily frequency of routine cleaning; increasing
the total number of working hours for cleaning
staff; or recruiting additional cleaning staff.
They observe, “All three studies demonstrated
a reduction in either environmental contami-
nation and/or HAIs. However, no single study
examined the effect of an increased cleaning
time in isolation; therefore, it was not possible
EVS is
to determine whether these outcomes were due
moving into
to the increased time spent cleaning or other
elements of the intervention.”
a time of
The observational component of the study
recognition
by Scott, et al. (2017) was conducted in the
and acceptance clinical skills laboratory of a university in the
UK. Nine participants cleaned selected items
as peers
of communal patient care equipment and the
duration of cleaning for each item was recorded
of other
using a stopwatch. Seven high-touch items of
healthcare
care equipment were chosen from the published
professionals.” literature: bed frame, bed rails, bedside table,
call system, notes trolley, blood pressure (BP)
— John
cuff and intravenous (IV) drip.
Scherberger
The participants included two infection
control nurses, three hospital domestic staff
and four non-clinical infection control staff.
Involvement of the non-clinical staff was used to estimate
the time taken by newly employed domestic staff without
any prior training; in such circumstances, the domestic staff
provided a demonstration of the cleaning procedure for
each item in advance.
Of the seven high-touch items of communal patient-care
equipment, Scott, et al. (2017) found that the bed frame
required the longest average time to clean (166.3 seconds),
followed by the bedside table (83.4 seconds). In contrast,
the call system (31.3 seconds) and the blood pressure cuff
(29.0 seconds) underwent the shortest mean cleaning times.
The researchers determined that there were no statistically
significant differences between non-clinical, nursing and
domestic staff in the average time to clean.
The researchers note, “Relatively little research attention
has been paid to the physical components of decontamination,
such as the efficacy of different scrubbing actions or the
duration of time healthcare workers spend cleaning surfaces.
In light of this absence, we aimed to provide an estimate
of the time required for healthcare workers, including both
experienced and novice domestic staff, as well as nurses,
to clean selected items of reusable communal patient care.
The format of the observational component did incur several
limitations: in particular, the study did not intend to evaluate
the effectiveness of cleaning by different occupations. Rather,
it aimed to provide cleaning time estimates that represented
the variable experience of healthcare workers in the NHS.
This is particularly noteworthy when considering the high
level of staff turnover for hospital domestic workers in the
UK. However, despite the broad occupational range of
participants, only nine individuals volunteered for the study
and a larger sample size might have improved external
validity of the estimates. The higher proportion of infection
control staff might be expected to have raised cleaning times
16
through greater thoroughness, yet Xu et al. (2015) found that
infection control professionals were less effective at cleaning
high-touch surfaces than environmental service workers.”
Coming at the issue from another angle, Clifford, et al.
(2016) sought to determine whether cleaning thoroughness
(dye removal) correlates with cleaning efficacy (absence of
molecular or cultivable biomaterial) and whether a brief
educational intervention improves cleaning outcomes. In
this before/after trial conducted in a newly built community
hospital, the researchers sampled 1,273 surfaces before and
after terminal room cleaning. In the short-term, dye removal
increased from 40.3 percent to 50.0 percent. For the entire
study period, dye removal also improved but not significantly.
After the intervention, the number of rooms testing positive for
specific pathogenic species by culturing decreased from 55.6
percent to 36.6 percent, and those testing positive by PCR fell
from 80.6 percent to 53.7 percent. For nonspecific biomaterial
on surfaces: a) removal of cultivable Gram-negatives (GN)
trended toward improvement; removal of any cultivable growth
was unchanged but acquisition (detection of biomaterial on
post-cleaned surfaces that were contaminant-free before
cleaning) worsened; removal of PCR-based detection of
bacterial DNA improved, but acquisition worsened; and
cleaning thoroughness and efficacy were not correlated.
As Clifford, et al. (2016) observe, “Although leading
experts continue to debate the optimal approach for assessing
relationships between biomaterial and cleaning outcomes,
they agree that more sensitive detection assays are needed,
along with comparative effectiveness assessments and linking
study results to patient centered outcomes.”
They continue, “The most efficient approach to monitor
and improve cleaning outcomes and whether cleaning
thoroughness correlates with DNA removal remain important
unanswered questions. Here, we define cleaning thoroughness
as whether 90 percent of an invisible marking dye has been
removed and cleaning efficacy as whether a surface has
detectable biomaterial following terminal cleaning. Biomaterial
is further separated into species-specific or total nonspecific,
and detected either by PCR or culture, and ‘efficacy’ includes
both removal of biomaterial from previously dirty surfaces, and
absence of biomaterial on post-cleaned surfaces that were
contaminant-free before cleaning. Conventional paradigms
and intuition suggest that the more training or education
and follow-up ‘refresher’ sessions the better. However, it
has been shown that a single, brief intervention session
may favorably affect behavioral outcomes, such as when a
physician mentions the importance of smoking cessation or
weight loss in a single patient encounter. It has also been
shown that repeated and intense interventions can impact
cleaning outcomes; less explored is whether a single, brief
intervention session can improve cleaning staff performance.
If effective, one brief educational session would be preferable
to more numerous long sessions for several reasons. First, a
single session would require less time and money, and would
minimize the ‘training fatigue’ associated with a hospital staff
obligated to complete an ever-increasing number of training
requirements. Second, in some hospitals for several reasons
(extended absences, short term hires, competing demands,
etc.) personnel might not have the opportunity to receive
multiple reinforcing sessions. Finally, interventions have not
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