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been widely studied at evidence-based design (EBD)-facilities.
Although a single, brief intervention might be ineffective at a
conventional facility, in an EBD hospital, with the panoply of
patient safety, staff ergonomic, and environmental features,
it may be sufficient to see an effect.”
The bottom line, according to Clifford, et al. (2016) was
that cleaning thoroughness did not correlate with the removal
of DNA or cultivable bacteria from contaminated surfaces.
The researchers observe, “By linking results to HAI rates,
and providing a comparative assessment of two widely used
monitoring systems (fluorescent dye removal and cultures) to
a sensitive and specific molecular assay, this study addresses
some of the critical knowledge gaps recently listed in a
systematic review of environmental cleaning. By providing
materials and concepts for enhanced monitoring and training
of environmental cleaning, the findings readily translate into
better practices and improved patient safety.”
They continue, “Our results suggest that the mere training
of cleaning personnel without changing the cleaning methods
is unlikely to result in significant improvement of hygienic
quality of hospital surfaces. With that in mind, consideration
should be given to revising educational and training materials
for cleaning staff. The revision should include the importance
of environmental DNA in HAI, the potential for more vigorous
efforts to increase contamination, especially with DNA, and
noting the increasing discoveries of disinfectant-tolerant or
resistant organisms. The revision could also re-emphasize the
proper use of cleaning wipes and not passing more than one
time with the same side of the wipe.”
Clifford, et al. (2016) note that the reduction in molecular
detection of target organisms, along with removal of general
nonspecific biomaterial, suggest that their study’s intervention
had some impact and that the cleaning staff was attempting
to clean more vigorously: “This is further supported by finding
that cleaning thoroughness improved for four of the five
surfaces most frequently harboring cultivable biomaterial, while
it decreased for four of the five surfaces least likely to harbor
the same. This is consistent with the cleaning staff redirecting
their efforts to the most poorly cleaned/dirtiest surfaces at the
expense of the least contaminated surfaces after receiving
the surface-specific results during the intervention. Notably,
acquisition significantly worsened after the intervention.”
The researchers explain that “even a minimal intervention
with good intention can have untoward effects. Perhaps
performance feedback at the surface-specific level is a
double-edged sword and fosters the natural human tendency
to take shortcuts or pay less attention to areas believed to
be trouble free. Or, as Rupp, et al. (2013) found, time spent
cleaning is not correlated with cleaning thoroughness. Perhaps
another revision to training materials for cleaning staff should
be a reminder that if time is limited, reallocating cleaning
efforts among surfaces can be counterproductive. In other
words, it is not necessary to ‘rob Peter to pay Paul.’”
Finally, Clifford, et al. (2016) emphasize that while thorough
cleaning does not guarantee effective cleaning, “the successful
removal of contaminants without additional deposition of
biomaterial (especially DNA or biocide tolerant organisms)
might indeed necessitate more time spent cleaning.”
Scherberger is optimistic that room turnover times are
among the issues that will receive renewed attention as the
impact of environmental hygiene continues to be studied and
better understood and appreciated.
“Environmental services and infection prevention are
finally receiving the recognition as the essential professional
disciplines they are,” he says. “EVS has always been the lowest
paid and least respected department in a hospital, although,
without them, a hospital would close. For far too long, EVS
was considered a department with a primary purpose of
providing an aesthetically pleasing environment. This attitude
was contrary to the importance Florence Nightingale viewed
her on orderlies. Housekeepers replaced orderlies, and EVS
technicians have replaced housekeepers. All three professions
had and have a duty to do what is morally and ethically right
for patients, staff, and visitors. The only way to defeat what
is not moral, ethical, or truthful is to tell it ‘no.’”
Scherberger continues, “For far too long, most EVS
department budgets realized cuts year after year; all the
while told to do more with less. This far-reaching requirement
resulted in healthcare environments being clinically deficient
and contributed to HAIs. Multiple scientific studies attested to
the clinical deficiency that resulted from the chronic wasting
disease EVS departments were suffering. Studies showed that
shortages in EVS resources and shortcuts they were required
to take were detrimental to patients. Without saying so, this
was a moral dilemma foisted upon concerned and dedicated
EVS professionals. With the publishing of so many science and
data-driven studies, EVS is moving onto the path on which it
belongs, maintaining healthcare environments that are free
of environmental surface contamination and that support
safety, service, and efficient and effective operations.”
Scherberger continues, “EVS is moving into a time of
recognition and acceptance as peers of other healthcare
professionals. But this recognition requires a fortitude not
voiced in the past. EVS must confidently find its voice and
say: ‘No, we will not take shortcuts on the path to doing
what is right. No, we will not bend or break the rules of
what protects our patients for expediency or personal benefit
for us. No, we will not allow distractions or unrealistic time
constraints to destroy our moral authority. Yes, we will do
what is right, fair, just and honorable.’” 
References:
Clifford R, Sparks M, et al. Correlating Cleaning Thoroughness with
Effectiveness and Briefly Intervening to Affect Cleaning Outcomes: How
Clean Is Cleaned? May 19,2016. PLoS ONE 11(5): e0155779. https://doi.
org/10.1371/journal.pone.0155779
Coppin JD, Villamaria FC, et al. Increased time spent on terminal cleaning
of patient rooms may not improve disinfection of high-touch surfaces. Infect
Control Hosp Epidemiol. 40 (5): 605-606, 2019. DOI:
Macario A. Are Your Hospital Operating Rooms “Efficient”? A Scoring
System with Eight Performance Indicators. Anesthesiology 2006; 105:237-40.
Pederson A, Getty Ritter E, Beaton M, Gibbons D. Remote video auditing
in the surgical setting. AORN J. 2017;105(2):159-169.
Peters A, Otter J, et al. Keeping hospitals clean and safe without breaking
the bank; summary of the Healthcare Cleaning Forum 2018. Antimicrobial
Resistance & Infection Control. Vol. 7, No. 132. 2018.
Rupp ME, et al. The time spent cleaning a hospital room does not
correlate with the thoroughness of cleaning. Infect Control Hosp Epidemiol.
34(1), 100-102. 2013.
Rupp ME, et al. Optimum Outlier Model for Potential Improvement of
Environmental Cleaning and Disinfection. Infect Control Hosp Epidemiol. Vol.
35, No. 6. Pp. 721-723. June 2014.
Scott D, Kane H, and Rankin A. ‘Time to clean’: A systematic review and
observational study on the time required to clean items of reusable communal
patient care equipment. J Infect Prev. 2017 Nov; 18(6): 289-294.
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