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Environmental Services and Infection Control & Epidemiology, University of Michigan Hospital
Standardizing the Monitoring the Process of Inpatient Room Cleaning to Reduce the Spread of Hospital Acquired Infections
Final Report
April 23, 2010
To: Environmental Services, University of Michigan Hospital Mr. Jim Becker, Staff Development Manager UHB2B302 1500 E. Medical Center Drive Ann Arbor, Michigan 48109 Mr. Kevin Lowry, Staff Development Manager UHB2B302 1500 E. Medical Center Drive Ann Arbor, Michigan 48109 Infection Control and Epidemiology, University of Michigan Hospital Ms. Kathy Petersen, MS, CIC, Infection Control Practitioner 300 N. Ingalls – NI8B06 Ann Arbor, Michigan 48109 Programs and Operations Analysis, University of Michigan Hospital Ms. Sheri Moore, Lead and Lean Coach 2101 Commonwealth Suite A
Ann Arbor, Michigan 48105 Industrial and Operations Engineering, IOE 481, University of Michigan Dr. Mark Van Oyen, Supervising Faculty Member Mr. Brock Husby, Supervising Graduate Student Instructor 1205 Beal Ave Ann Arbor, Michigan 48109
From: Industrial and Operations Engineering, IOE 481 Team 2, University of Michigan Melissa Chen, Student Michelle Delaney, Student Lantei Takona, Student Yiwen Xu, Student 1205 Beal Ave Ann Arbor, Michigan 48109
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Table of Contents
Executive Summary ...................................................................................................................5
Introduction ...........................................................................................................................5
Key Issues .............................................................................................................................5
Goals .....................................................................................................................................5
Methodology .........................................................................................................................5
Findings.................................................................................................................................6
Literature Search ..............................................................................................................6
Observations and Interviews with EVS Staff ..................................................................6
Surveys .............................................................................................................................6
Interviews .........................................................................................................................7
Active Review ..................................................................................................................7
Conclusions ...........................................................................................................................7
Recommendations .................................................................................................................7
Introduction ................................................................................................................................9
Background ................................................................................................................................9
Key Issues ................................................................................................................................11
Goals and Objectives ...............................................................................................................11
Project Scope ...........................................................................................................................11
High-Touch Surfaces and Isolation Surfaces In Scope .......................................................12
High-Touch Surfaces and Isolation Surfaces Out of Scope................................................12
Changes to Initial Scope .....................................................................................................12
Expected Impact.......................................................................................................................13
Methodology ............................................................................................................................13
Data Collection ...................................................................................................................13
Literature Research .......................................................................................................13
Orientation ....................................................................................................................13
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Observation ...................................................................................................................14
Active Review ...............................................................................................................14
Benchmarking ...............................................................................................................15
Interviews and Surveys .................................................................................................15
Findings....................................................................................................................................15
Literature Search: Patient room cleaning and monitoring methods...................................15
Observation of Cleaning Process .......................................................................................16
Observations and Interviews with EVS Staff ...................................................................16
Individual Cleaning Methods .......................................................................................16
Various Cleaning Time ................................................................................................16
Existing List Used Infrequently ...................................................................................16
Working in Pairs ..........................................................................................................17
Surveys of EVS Custodians: Positive responses ..............................................................17
Interviews with Medical Staff: Sufficient quality of work ...............................................18
Benchmarking ...................................................................................................................18
Active Review ...................................................................................................................19
Bleach Concentration Test ................................................................................................19
Room Cleaning Analysis ............................................................................................20
Process Stability in Time Order ...........................................................................20
Percent of Rooms Cleaned 100% ........................................................................21
Distribution of High-touch Surfaces Missed by Unit ..........................................21
Conclusions ..............................................................................................................................23
Alternative Considered ............................................................................................................23
Incentives ..........................................................................................................................23
Annual Re-Training and Orientations ...............................................................................23
Update Existing Checklist.................................................................................................24
Recommendations ....................................................................................................................24
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Appendix A – Spray Checklist ................................................................................................26
Appendix B – Staff Surveys ....................................................................................................27
Appendix C – Telephoned Hospital Questions Literature Research References ....................28
Appendix D – Research References ........................................................................................29
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List of Tables and Figures
Table 1: Positive Responses from Surveys ..............................................................................17
Table 2: Hardest, Easiest Surfaces to Clean, and High-Touch Surfaces .................................18
Table 3: Summary of Benchmarking Results ..........................................................................19
Table 4: Bleach Concentration Test Statistics Summary .........................................................19
Table 5: Preliminary Results Summary ...................................................................................20
Table 6: Rooms Cleaned 100% for Each Unit .........................................................................21
Table 7 : Time Spent by Each Supervisor ...............................................................................25
Figure1: C. diff Rates in 2009 ..................................................................................................10
Figure 2: Active Review Process .............................................................................................14
Figure 3: Discharge Room Cleaning Process ..........................................................................16
Figure 4: The Percentage of Spots Cleaned vs. Time ..............................................................21
Figure 5: Surface with Highest Percentage Missed in 8B .......................................................22
Figure 6: Surface with Highest Percentage Missed in CVC5 ..................................................22
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EXECUTIVE SUMMARY
Introduction
According to the Infection Control and Epidemiology department at the University of Michigan Hospital, reducing the spread of Clostridium difficile (C. diff) is high priority. This hospital acquired infection is mostly contracted by patients with weak immune systems. To mitigate the spread of the bacterium, Environmental Services has provided the custodial and medical staff with strict prevention precautions and hand hygiene instruction to ensure patient health and safety.
The Environmental Services (EVS) and Infection Control & Epidemiology departments (IC&E) would like to develop an on-going quality monitoring process, and identify surfaces of improvement in the quality of discharge room cleanings. The participating departments would also like to know which surfaces are most often touched by the patient and see data representing what surfaces are being cleaned thoroughly based on the current techniques. EVS understands the importance of ensuring quality cleaning and is partnering with IC&E to address these issues and improve the cleaning techniques in place.
Key Issues
The following were the key issues specifically driving this project:
• The spread of the C. diff bacterium is a high priority at the University of Michigan Hospital, and IC&E and EVS would like to reduce the rate of infection
• The EVS department sees the need to implement an on-going monitoring process for discharge room cleaning, in addition to the education regarding proper room cleaning procedures the EVS custodians currently receive
Goals Environmental Services and Infection Control requested that the team:
• Define high-touch areas within patient rooms to be monitored
• Define areas where current techniques are implemented well
• Develop repeatable monitoring process of inpatient room cleaning
• Provide recommendations for a quality metric
Methodology To complete this request, the IOE 481 team examined the current methods in the field that were being researched and implemented. The IOE 481 team conducted a literature search consisting of 32 articles from Infection Control journals and hospitals to find existing data and methodologies performed at other hospital facilities, surveyed 32 EVS custodians, interviewed 15 medical staff members, participated in EVS orientation and room cleaning, and observing the flow of EVS custodians through the discharge room cleaning process. The IOE 481 team also piloted an
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active review process with a black light test with EVS custodians during 21 discharge room cleanings. During the active review process, a surrogate germ was sprayed on surfaces that are frequently touched by patients, visitors, and medical staff. After the room was cleaned, team members, along with the custodian that had cleaned the room, reviewed the sprayed surfaces with a black light. The review was used as a learning tool to provide real-time feedback of cleaning performance to custodians. The concentration of bleach used in cleaning was also tested with bleach test strips during the active review
From the information gathered from the literature search, surveys, interviews, orientation, observations, and active review, the team developed an ongoing monitoring process for the Environmental Services department using the black light test. Two models were developed to assist the department in tracking cleanings. The first allows supervisors to input performance data collected from the individual cleanings of each custodian. The second model will be used by EVS management to track the monthly performance of cleanings by supervisor. This model will be used to identify where improvements can be made to increase overall hospital performance.
Findings
The team gathered the information and data below throughout the course of the project.
Literature Search • Similar black light tests and methods are used in other hospitals and facilities and in
many cases resulted in a higher frequency of surfaces cleaned
Observations and Interviews with EVS Staff • Custodians use individual cleaning methods, such as a liquid bleach solution or
Clorox wipes; or in following the top-down cleaning method required
• The time taken to clean a room varies among staff, due to patient circumstances and varying custodian beliefs of the thoroughness of cleaning required
• All EVS custodians have a list attached to each cart with the areas to clean daily and weekly, including many of the high-touch areas that the team identified
• The custodians do not look at list during each cleaning because they feel that they have the necessary experience to complete the job without consulting the list
• Many custodians enjoy working in teams when cleaning rooms
Surveys
Of the 32 completed surveys that the team received from the EVS staff: • The majority of custodians strongly agreed that the expectations for room cleaning are
well laid out (65.6%), that there is enough education about room cleaning (56.3%), and that they are able to keep up with their workload (37.5%)
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• 7 custodians said that the bed is the hardest area to clean, and 8 said the high surfaces (lights, ceiling, vents) were the hardest. 6 custodians said that the bathroom surfaces were the easiest areas to clean. 11 custodians identified the bed and the door/door handles as high-touch areas
Interviews Of the 15 doctors and nurses interviewed:
• There was unanimous feedback that a sufficient quality of work is being done by the Environmental Services Staff to ensure overall hospital cleanliness
Active Review The following results were gathered from the active review process on 21 room cleanings:
• 43% of rooms monitored were 100% clean • The drawer handle, faucet handle, and bathroom rail were only cleaned 71% of the time,
and the bathroom light 79% of the time • All 9 of the bleach tests performed met the minimum concentration required
Conclusions Findings from methodology led to the following conclusions:
• EVS staff have established individual cleaning habits, such as different cleaning procedures (top-to-bottom), or preference toward certain cleaning equipment (liquid bleach solution or Clorox wipes)
• Custodians are satisfied with their work and work requirements and believe expectations are well laid out, there is sufficient education about room cleaning, and that they are able to keep up with their work load
• Doctors and nurses interviewed believe that a sufficient quality of work is being done by the EVS staff to ensure overall hospital cleanliness
• There are recurring surfaces that are missed in cleaning throughout different hospital units
Recommendations To address the issues at hand, the team recommends that Environmental Services and Infection Control & Epidemiology implement the following:
• EVS and IC&E continue to partner and form a subgroup to determine how to implement the new monitoring process. They will decide whether the process should be on-going in all units or whether it should be used to target specific units during the year. The subgroup will also determine the frequency of the blind black light test.
o The following table should be used to aid in allotting an appropriate amount of time for EVS supervisors to complete the monitoring process. Note that if supervisors perform the black light test on more than one custodian at a time, the
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overall time to complete the tests would decrease since they the spray could be applied in one room while a custodian cleans the previous room.
• Table 1: Time Spent by Supervisor per Observations Made Monthly
Number of Times Each Custodian is
Tested (monthly)
Approximate Times per Black-light Test
(minutes)
Maximum Time Each Supervisor Spends a
Month (hourly)
Observations Collected per
Supervisor (monthly)
1 45 15 20 2 45 30 40 3 45 45 60 4 45 60 80 5 45 75 100
• EVS supervisors perform the blind black light test used by the team on each of the custodians under their direct supervision
• EVS and IC&E subgroup consider other areas this process could be used for, such as the OR, and to expand on daily and weekly cleanings.
• EVS and IC&E subgroup further investigate the variation in cleaning practices so as to determine what custodial cleaning procedures should be standardized and what should be left to personal preference.
• Update the current EVS custodial checklist to include the high touch surfaces listed in Appendix A.
• Incorporate results from the monitoring process with the current incentive plan.
• Require all custodians to undergo annual retraining and orientation sessions.
• EVS and IC&E management monitor the Excel monitoring chart module to continually develop competitive standards. Supervisors enter all collected data from the black light test into the Excel KPI module to calculate the percentage of rooms cleaned 100% of the time
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INTRODUCTION
The University of Michigan Hospital (UM HOSP) has currently recognized reducing the spread of Clostridium difficile (C. diff) bacterium during patient care as high priority, according to the Infection Control & Epidemiology department of the University of Michigan Health System. C. diff is a hospital acquired infection and is often contracted by patients with weak immune systems. Patients with such infections are put in isolation to mitigate the spread of the C. diff spores. The cleaning of inpatient rooms at discharge is currently performed by the Environmental Services staff. Doctors and other patient attendants also follow strict infection prevention precautions such as proper hand hygiene techniques to control the spread of infection to other patients. Along with the precautions in place, Environmental Services and Infection Control would like to further reduce the spread of C. diff to ensure patient health and safety.
The Environmental Services (EVS) and Infection Control & Epidemiology departments (IC&E) requested that an IOE 481 team define surfaces within inpatient rooms to monitor, develop an on-going quality monitoring process, and identify surfaces of improvement to serve as a tool to maintain a high standard of quality in cleaning based on the findings from this study. The participating departments would also like to know which surfaces are most often touched by the patient and see data representing which surfaces are being cleaned thoroughly based on the current techniques. EVS understands the importance of ensuring quality cleaning and is partnering with IC&E to address these issues and improve the cleaning techniques in place.
To develop a monitoring process for inpatient room cleaning to serve as a quality metric, the team has observed and analyzed the environmental cleaning and hygiene techniques that are currently implemented in the UMHS facility. The team has also performed a literature search to determine high-touch surfaces, or surfaces that patients contact repeatedly, within inpatient rooms. In addition, the team has developed a standardized monitoring procedure of the high-touch surfaces that may be implemented throughout the University of Michigan Health System to effectively sustain a clean environment. To achieve these goals, the team conducted a survey to gather subjective data on the current overall process of cleaning techniques within inpatient rooms and performed a study using a fluorescent germ surrogate (Clue Spray) to analyze how well a room was cleaned after a discharge. This data was be used to develop a versatile repeatable methodology that may be used in other surfaces of the UMHS facility to reduce the spread of hospital acquired infections. This report presents our methodology, findings, conclusions, and recommendations.
BACKGROUND
According to the Infection Control and Epidemiology department (IC&E) Clostridium difficile (C. diff), has been present at the University of Michigan Hospital. C. diff is a hospital acquired bacterial infection, meaning patients contract the infection during their stay at the hospital.
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Although many measures have been taken to control the situation, the infection remains at levels higher than the goal of 0.6 cases of hospital acquired C. diff per 1000 patient days (IC&E) as shown in Figure 1.
Figure 1: C. diff Rates in 2009
Figure 1 shows that over the last 14 months, the rate of C. diff in the University of Michigan Hospital has consistently been above the desired rate of 0.6 cases per 1000 patient days. Environmental Services understands the need for a quality monitoring process to maintain the University of Michigan Hospital’s high standard of quality.
C. diff is a bacterium that naturally resides within the body. However, when patients whose immune systems are compromised, as they often can become in hospitals by way of antibiotics or surgeries, the C. diff bacteria overproduce and cause the patient to experience severe diarrhea and intestinal discomfort. C. diff is unlike other hospital acquired infections in that it produces spores that proliferate in the patient’s immediate environment. Doctors, nurses, and those who come into contact with the patient must first use Purell, an alcohol based hand sanitizer, treat the patient, then wash their hands with soap and water for 15 seconds upon leaving the patient’s room, since the C. diff bacteria cannot be removed by alcohol based hand cleansers. According E. Dubberke2, the mean lengths of hospital stays were found to increase as a result of C. diff from 2.6 to 4.5 days, and the rate of mortality among adult patients was 6.9% at 30 days and 15.7% at 1 year. The Centers for Disease Control and Prevention estimates that more than 1.7 million patients become infected with C. diff during the course of treatment each year, costing the healthcare industry approximately $33 billion in direct medical costs.
A study conducted by P. Carling3, discussing the prevention of C. diff states that proper protocol in cleaning patient rooms is essential. E. Goodman1 conducted a study over several hospitals that showed that many hospital employees do not consistently follow the entire cleaning procedure laid out by the hospital. E. Goodman observed that some high-touch surfaces are skipped over in the cleaning process. Also, it is difficult to monitor how well these high-touch surfaces are being
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cleaned because the C. diff bacteria are particularly difficult to culture. Therefore, hospitals must resort to other methodologies such as monitoring the cleaning procedure of patient rooms. Implementing a standard monitoring process for the patient room cleaning ensures a high quality of cleaning of all high-touch surfaces.
KEY ISSUES The following key issues created a need for this project:
• The spread of the C. diff bacterium is a high priority at the University of Michigan Hospital, and IC&E and EVS would like to reduce the rate of infection
• The EVS department would like to implement a quality monitoring process in addition to the education regarding proper room cleaning procedures the EVS custodians currently receive
GOALS AND OBJECTIVES
The primary goal of this project was to develop a standardized monitoring process that measures the quality of the cleaning process of inpatient rooms after discharge. To achieve this goal, the team has completed the following steps:
• Identified high-touch surfaces within patient rooms • Identified variation in discharge patient room cleaning and informed EVS staff of these
variations • Identified current concerns regarding the implemented cleaning procedures through
subjective surveys from the medical and custodial staff • Piloted a methodology using a germ surrogate (Clue Spray)
• Piloted a monitoring process with the initial data
PROJECT SCOPE
The student team examined the cleaning activities of inpatient rooms at discharge for units 5B, 8B and CVC5 in the University of Michigan Hospital. The primary parties involved in this project included Infection Control (IC&E) and Environmental Services (EVS). Doctors, nurses, other medical staff, and custodians of the three units were involved in impromptu interviews.
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High-Touch Surfaces and Isolation Surfaces In Project Scope The project included only the following high-touch surfaces of the general inpatient rooms and specific isolated rooms of 5B, 8B and CVC5 at discharge:
o Remote o Bed rail o Over bed table o Drawer handle o Room light switch o Door handles (inside and outside)
Faucet handles Sink counter top Toilet handle Toilet seat Bathroom rail Bathroom light switch Bathroom door handles (inside and
outside)
The scope of the project also included specific isolated rooms with green, purple, pink and yellow signs. These signs indicate that specific contact precautions are required when entering the room. The team also tested the concentration of bleach used in the cleaning process.
High-Touch Surfaces and Isolation Surfaces Out of Scope In the University of Michigan Hospital rooms with blue signs are isolated for respiratory isolation precautions, and the rooms were not included in this project. For semi-private rooms, high-touch surfaces in the bathroom, which are shown in the above list with check bullets, were not monitored. Also, high-touch surfaces other than those listed above, such as stethoscopes, charts, commodes, linens and patient equipment were not examined. The team did not study the activities associated with the daily cleaning of patient rooms. Also, the custodians’ cleaning procedures were out of scope of the project. Finally, any other hospital surfaces, the center core, and all other units in the hospital were not studied during this project.
Changes to Initial Scope During observation and piloting the monitoring methodology, the team found that certain surfaces were unusable for the study. The Clue-spray remained on the surfaces of the soap dispenser, phone receiver, and arm rests on chairs even after the surfaces were cleaned vigorously. The unusable surfaces were all plastics; the team speculates that the surfaces may have been too porous and absorbed the surrogate germ spray. These surfaces were place outside of the project scope for the active review process.
o Semi Private *All bulleted surfaces for Private
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EXPECTED IMPACT
The team used the observations and analysis from the black light test, survey results, and research on types of monitoring processes to formulate a method for monitoring the cleaning of the patient rooms upon discharge.
The team expects that the recommended method will:
• Reduce the spread of bacteria throughout the hospital • Improve patient safety by reducing exposure to health risks • Reduce levels of C. diff in the hospital
The recommendations from this study will also result in increased employee satisfaction and indirect reduced hospital and patient costs.
METHODOLOGY
To execute this project, the team used the following methodology: data collection, analysis, and recommendations. The primary parties that were involved in the process were the custodians, patients, Environmental Services supervisors, doctors and nurses.
Data Collection Gathering data was an integral part of this project and was essential for understanding the current cleaning and monitoring methods in patient rooms and for developing recommendations.
Literature Search The team studied over 32 academic articles relevant to patient room cleaning and monitoring methods. This literature included previous IOE 481 student projects, scholarly articles about the spread of C. diff and quality monitoring in hospitals recommended by the Infection Control Practitioner, and journals published by the American Journal of Infection Control, Journal of Hospital Infection, along with others listed in Appendix C.
Orientation Team members participated in Environmental Services staff orientation to understand the current staff cleaning methods and procedures. During the orientation, the team also completed tests required for the EVS staff. The Staff Development Manager also acquainted the team with EVS supervisors, nurse managers and supervisors connected to the project. Following the EVS staff orientation, each member of the team participated in a discharge room cleaning with an EVS staff member. From this orientation, the team learned the proper safety precautions for the cleaning process, as well as the proper cleaning agents to use in various situations. The team also gained a better understanding of current staff cleaning methods and procedures.
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Observation The team has initially observed approximately 15 hours of the current EVS staff flow through the University of Michigan Hospital during the discharge cleaning process. From the observations, the team developed a the Active Review process facilitate data collection by tracking discharges using the hospital bed-tracking system and by coordinating with clerks and custodians.
Active Review The team conducted an active review of EVS custodians for approximately 84 hours. The following methodology was developed to monitor and actively review the Environmental Services (EVS) custodians’ thoroughness of cleaning with a black light test. This test was used as a learning tool to educate custodians as they cleaned.
Figure 2: Active Review Process
A high-touch area was considered to have been thoroughly cleaned if the clue spray was removed or appeared smeared under the black light. Based on the results of the black light test, the team identified the high-touch surfaces being cleaned thoroughly and those that could be improved. The list of high-touch surfaces examined is in Appendix B, and was used to record whether the area was wiped clean.
The team piloted this methodology and collected approximately 20 observed cleanings over a span of three and a half weeks. In monitoring private rooms, all surfaces on the high-touch area checklist were examined. In semi-private rooms, only the “dedicated” surfaces were examined.
During this process, the team also used Bleach-Rite ? Test Strips to evaluate the concentration of bleach used to clean the patient discharge rooms. The strips were dipped into the custodians’ bleach buckets for ten seconds, and then removed. After 60 seconds, the color of the strip was compared to the color prescribed for the correct bleach concentration on the bottle. The bleach test results were also recorded on the high-touch area checklist.
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Benchmarking
During March and April, the team telephoned other hospitals involved with the fluorescent germ surrogate studies performed by P. Carling3 to benchmark the project’s findings and data and to assist in formulating recommendations. The team asked the hospital questions regarding the type of quality monitoring process in place and the department of the hospital that was responsible for maintaining the process. The questions are listed in Appendix D. The Infection Control departments of the following hospitals were contacted:
• Toledo Hospital (Toledo, OH) • Kaiser Permanente Medical Center (Sacramento, CA) • Nebraska Medical Center (Omaha, NE) • University of Iowa Hospitals (Iowa City, IO) • Washington Hospital Center (Washington, D.C.) • Union Memorial Hospital (Baltimore, MD)
Interviews and Surveys Team members informally interviewed 15 members of the medical staff, including doctors, nurses, and technicians, as well as the custodial staff. The interviews provided insight into the current beliefs regarding overall cleanliness.
The team also distributed surveys to all of the EVS custodians at the University of Michigan Hospital and received 32 completed surveys for analysis. The survey provided a quantitative measure of the custodian’s level of comfort with the responsibilities of the room cleaning process. The questions asked in the interviews and surveys included:
• Education of work responsibilities • Clarity of expectations • Appropriate workload • Obstacles preventing optimal performance
FINDINGS
This section provides details and an analysis of the findings based on the implemented methodology used in this study.
Literature Search: Patient room cleaning and monitoring methods The team studied over 32 academic articles relevant to patient room cleaning and monitoring methods, which are listed in Appendix C. The literature search showed similar tests and methods used in other hospitals and facilities. A similar black light test was used in hospital intervention studies, and resulted in an increased frequency of black light marks being removed from the
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surfaces in the hospital. This black light study also resulted in a reduced likeliness of an environmental culture of Methicillin-resistant Staphylococcus aureus (MRSA) or Vancomycin-Resistant Enterococcus (VRE).
Observation of Cleaning Process
Through observation, the team gained a better understanding of the current EVS custodian flow through the discharge room cleaning process. It was observed that the clerks use the hospital bed-tracking system to page the EVS custodians when a patient has been discharged from the hospital. The following chart illustrates the discharge room cleaning process.
Figure 3: Discharge Room Cleaning Process
Observations and Interviews with EVS Staff Through observations and interviews with EVS staff, the team found the following four things about discharge room cleaning processes. Individual Cleaning Methods Custodians use individual cleaning methods when cleaning the room. Some use rags and bleach bucket while others use Clorox wipes. Some follow the required top-down cleaning process while others don’t. Various Cleaning Time Although all rooms should be cleaned within 45 minutes of page, time taken to clean a room varies among staff due to varying beliefs of the thoroughness of cleaning required. Existing List Used Infrequently EVS staff has an existing list attached to each cart, which lists surfaces to clean daily and weekly, including many high-touch surfaces the team found. However, staffs don’t look at this list during
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each cleaning, because they feel they have the necessary experience to complete the job without consulting the list Working in Pairs Many custodians enjoy working in pairs when cleaning rooms so they can get enough and timely help if needed. Surveys of EVS Custodians: Positive responses
Table 1 displays the results of the 32 surveys completed by EVS custodians.
Table 1: Positive Responses from Surveys
Strongly Disagree
Strongly Agree
1 2 3 4 5 6
The expectations for cleaning a room are well laid out
3.1%
31.3% 65.6%
There is enough education about cleaning a room
3.1%
6.3% 34.4% 56.3%
I am able to keep up with my workload
3.1% 6.3% 18.8% 37.5% 34.4%
The highlighted cells of Table 1 indicate where the majority of answers were. The survey results show that most custodians believe that the expectations for cleaning a room are well laid out, that there is enough education about room cleaning, and that they are able to keep up with their workload.
Table 2 displays the most common answers regarding the hardest and easiest surfaces to clean, as well as surfaces the custodians believed to be high-touch.
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Table 2: Hardest, Easiest Surfaces to Clean, and High-Touch Surfaces
Hardest to Clean Easiest to Clean High-Touch Surfaces
Bed 7 1 11
Bathroom Services (Toilet/Sink)
4 6 4
Doors/Door Handle 0 1 11
High Surfaces (Lights/Ceiling/Vents)
8 1 0
Light Switches 0 0 4
TV Remote 0 0 2
Table 2 shows that most custodians believe the bed and high surfaces, such as the lights, ceiling, and vents to be the hardest to clean. They believe that the bathroom surfaces are the easiest to clean. Custodians frequently identified the bed and doors as high-touch surfaces.
Interviews with Medical Staff: Sufficient quality of work
15 doctors and nurses from units 5B, 8B, and CVC5 were informally interviewed. From these interviews the team received unanimous feedback that a sufficient quality of work is being done by the Environmental Services Staff to ensure overall hospital cleanliness
Benchmarking
The IOE 481 team contacted five hospitals associated with P. Carling. Two hospitals replied. An IOE 481 team member called the Infection Control department for each hospital and presented the questions in Appendix D. A summary of results are presented in Table 3.
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Table 3: Summary of Benchmarking Results
Hospital Comments addressing Study to Develop Standardized Monitoring Process for Discharge Patient Room Cleaning
The Toledo Hospital
Currently conducting similar study. Based on results, there was an improvement in cleanliness from 47% to 80%. Ecolabs has a program similar to "Clue Spray" study and have purchased rights to the program.
Washington Hospital Center
Currently no process being implemented. ATP swabs are used to check bacteria count based on percentage.
Active Review
The information derived from active review consists of two parts. The first part, Bleach Concentration Test, summarizes results from testing concentration of bleach. The second part, Room Cleaning Analysis, is a statistical summary of room cleaning status. Bleach Concentration Test A total of 9 bleach concentration tests were performed during discharge room cleanings. Among those, 5 tests were performed in CVC5, 1 in 5B and 3 in 8B. The test will provided one of three possible results: less than 1:10 dilution, 1:10 dilution or 1:5 dilution. EVS would like the bleach to be a 1:10 dilution. A 1:5 dilution of bleach is stronger than the standard but is still sufficient. Table 4 summarizes the test results.
Table 4: Bleach Concentration Test Statistics Summary
Number Percentage 1:10 Dilution 1:5 Dilution 1:10 Dilution 1:5 Dilution
5B 0 1 0.00% 100.00% 8B 2 1 66.67% 33.33%
CVC5 1 4 20.00% 80.00% Overall 3 6 33.33% 66.67%
All of the bleach tests met the minimum concentration requirement. They had either 1:10 dilution or 1:5 dilution. In 5B, 100% of the bleach had a 1:5 dilution. In 8B and CVC5, 66.67% and 20% of the bleach had a 1:10 dilution, respectively. The overall percentage of bleach with a 1:10 dilution is only 33.33% , which is relatively low. It was found that the variation in bleach was consistent across different types of cleaner. Every liquid bleach solution tested had a 1:10 dilution, while the Clorox wipes were all at the higher dilution.
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Room Cleaning Analysis
The following table presents the preliminary results from the active review. The team analyzed the preliminary results using the following methods: process stability in time order, percentage of rooms cleaned 100% of the time, surfaces missed by unit.
Table 5: Preliminary Results Summary
High-Touch Surfaces Percentage of being cleaned
# of misses each unit 5B
(2S) 8B
(5S,1P) CVC5 (13P)
Remote 95%
1 Bed Rail 100%
Over Bed Table 100% Drawer Handle 71%
1 5 Room Light Switch 95%
1
Inside Room Handle 95%
1 Outside Room Handle 95%
1 Faucet Handle 71%
1 3
Sink Counter 86%
1 1 Toilet Handle 93%
1
Toilet Seat 93%
1 Bathroom Rail 71%
1 3
Bathroom Light 79%
1 2 Inside Bathroom Handle 93%
1
Outside Bathroom Handle 93%
1
The team observed a total 21 discharge room cleanings. Among all those, 7 were semi-private rooms and 14 were private rooms. Table 5 is a summary of the preliminary results. In Table 5, high-touch surfaces indicated by Italic are only checked for private rooms. Table 5 was used to view trends in missed surfaces. It shows that the drawer handle, faucet handle, bathroom rail, and bathroom light were commonly missed surfaces. It must be noted that each of the bathroom surfaces (in italics) missed in the private room of 8B were all part of the same room cleaned by one custodian. Process Stability in Time Order: For semi-private rooms, the team checked 7 high-touch surfaces and for private rooms, 15. The team observed different number of observed cleaning from different days. To show the process stability in time order, the team used the average percentage of spots cleaned as Y-axis and dates as X-axis. The chart is shown as Figure 4.
Same custodian, all in one room
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Figure 4: The Percentage of Spots Cleaned vs. Time Collected by IOE 481Team 2, February 20-March23 2010, N=21
Figure 4 shows that the percentage of spots cleaned does not change according to the change of time. The chart shows no obvious trend. Most of the time, this percentage is not high enough compared to a standard of hospital and it is not stable. Percent of rooms cleaned 100%: among all the 21 rooms reviewed, the team found 43% of them are cleaned 100%, meaning that the custodian hit every spot on the check list. Table 6 below shows a summary of room cleaned 100% for each unit.
Table 6: Room Cleaned 100% for Each Unit Unit # Rooms reviewed # Rooms 100% clean % rooms 100% clean 5B 2 2 100% 8B 6 3 50%
CVC5 13 4 31% Distribution of High-touch Surfaces Missed by Unit: From the preliminary data, different units missed different surfaces and the percentages of different missing surfaces were also different. To see this relationship, the team made the following two pie charts to show the distribution of high-touch surfaces missed. Figure 5 is for unit 8B and Figure 6 is for unit CVC5, separately. Since no missing surfaces are found in unit 5B, no pie chart was made.
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Figure 5: Surface with Highest Percentage Missed in 8B
Figure 6: Surface with Highest Percentage Missed in CVC5
For unit 8B, 16 spots are missed among 195 opportunities. The surfaces with highest percentage being missed are drawer handle, inside room handle and remote. Each is 23% of all the missing
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surfaces. For unit CVC5, 11 spots are missed among 50 opportunities. The surfaces with highest percentage being missed are drawer handle, faucet handle and bathroom rail. The percentages are 31%, 19% and 19%, separately. CONCLUSIONS Based on the team’s findings, the following conclusions were developed:
• EVS staff have established individual cleaning habits, such as differences in cleaning procedures (whether or not the top-to-bottom cleaning procedure is followed), preferences toward cleaning equipment (such as liquid bleach solution or Clorox wipes), and variations in total time for room cleaning
• Custodians are satisfied with their work and work requirements • Medical staff members, (doctors, nurses, clerks etc) believe that a sufficient quality of
work is being done by the Environmental Services Staff to ensure overall hospital cleanliness
• There are recurring surfaces that are missed during cleaning throughout the different hospital units
ALTERNATIVES CONSIDERED After analyzing the data from the cleaning observations, surveys, and interviews, the team discussed two alternative solutions to improve the current cleaning processes and procedures
• Provide incentives to custodial staff to award effort • Annual re-training and orientation sessions • Update existing checklist
Incentives Since multiple supervisors oversee custodial staffing teams, the team discussed integrating the already implemented incentive system of rewards/awards into the black light test monitoring system to highlight those individuals excelling above expectations. This system will serve as motivation and a desire to be publicly recognized for excellent services. Annual Re-Training and Orientation Due to the difficulty of individually monitoring each custodian as they perform their day-to-day tasks, providing the custodial staff with an annual re-training and orientation will serve as a refresher to their duties and proper procedures. An orientation will enable the custodial staff to perform at exceptional standards. Based on the literature search conducted, the team noticed that
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other hospitals implemented an educational period upon observation of unclean high-touch surfaces. Custodians were provided information as to what surfaces should be cleaned, proper procedures, and what surfaces require special attention when cleaning. Rather than addressing the issue of improper cleaning on an individual level, due to time efficiency, annual departmental re-training may serve to assist as a reminder. Update Existing Checklist Based on the current literature search conducted, the team suggests that Environmental Services and Infection Control & Epidemiology continue to update the existing custodial checklist to include the high-touch surfaces used in this study. This integration will enable the custodial staff to target a majority of high-touch surfaces within a room, which will lead to a more effective cleaning process. RECOMMENDATIONS
Based on the analysis of findings and conclusions, the team recommends that Environmental Services use the following elements to establish a quality monitoring system:
• EVS Supervisors- Supervisors will be responsible for tracking each individual custodian on their team. Tracking will be integrated into the daily tasks of the supervisor. Individual tracking will enable the identification of opportunities where improvement can be made.
• Subgroup of EVS and IC&E staff – A subgroup of both departments should be composed to further investigate the variation in cleaning practices so as to determine what custodial cleaning procedures should be standardized and what can be left to personal preference.
• Excel key performance indicator (KPI) module- The KPI module will be used to track each custodian’s performance using as standardized check list that will be completed by each supervisor and the percentage of rooms that were cleaned 100%. The supervisor will then submit the completed KPI module to the EVS management on monthly basis.
The KPI module will allow EVS management to compile the data from each supervisor. The overall output will provide the EVS management with an annual tracking system that will indicate performance for the entire department by month.
The monitoring chart will also be managed by each supervisor. The chart will provide output based on each custodians performance to serve as a visual aid. This chart will compare the desired performance rate with each custodian’s performance.
• Investigate other ways to apply the new process – EVS and IC&E should continue to investigate and integrate new high-touch surfaces that could be used within the active review as the monitoring process evolves. The new monitoring process could also be integrated into daily and weekly cleanings, or other areas of the hospital.
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The team proposes that EVS employ their supervisors to implement an on-going quality monitoring system, since supervisors already have an existing relationship with the custodial staff. The team recommends that the EVS supervisors perform the black-light tests. This process should be conducted by following a similar methodology to that which was piloted throughout this study. The team also recommends that a cross departmental subgroup between EVS and IC&E be formed to determine how to use the KPI tool in regards to ongoing overall monitoring of hospital units, or used for specific targeted units, or both. In addition, the subgroup will be responsible for determining how often the black light tests should be performed based on Table 7.
EVS can consult with IC&E to determine a statistically optimal amount of observations to be collected per month. EVS and IC&E can use the Table 7 to estimate the maximum amount of time EVS supervisors would require, depending on the number of black light tests performed. By batching the active review process, applying the spray to multiple rooms and then reviewing all at once, the supervisors will be able to spend less time waiting for rooms to be cleaned. The waiting process should be conducted with care to ensure that the active review is conducted prior to a new patient being admitted into that room.
Table 7: Time Spent by Each Supervisor
Number of Times Each Custodian is
Tested (monthly)
Approximate Times per Black-light Test
(minutes)
Maximum Time Each Supervisor Spends a
Month (hourly)
Observations Collected per
Supervisor (monthly)
1 45 15 20 2 45 30 40 3 45 45 60 4 45 60 80 5 45 75 100
EVS supervisors will perform the black light test on their assigned custodial staff. Following the test, each EVS supervisors should enter in the collected data into the Excel KPI module. The IOE 481 team will provide the Excel KPI module. The module will calculate the percentage of high-touch surfaces cleaned for each custodian. The collected data will eventually accumulate to enough data points to produce a monitoring chart. The monitoring chart will be used to monitor whether or not the percentage of high-touch surfaces cleaned is acceptable. The Excel monitoring chart module is directly connected to the Excel KPI module.
The team recommends that EVS continue to partner with Infection Control and Epidemiology to determine any new high-touch surfaces and develop competitive standards for the Excel monitoring chart module and also how often employees need to be checked to produce relevant results.
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Appendix A: Spray Checklist
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Appendix B: Staff Survey
Environmental Services
Custodian Survey
Preface: The purpose of this survey is to assist a student engineering team to develop a monitoring process for inpatient discharge room cleaning. Your input will greatly help the team to understand the cleaning process from a personal perspective and gain professional insight. Your responses will remain strictly anonymous.
1. What department do you work in? (Circle one) UMH CVC Mott
2. The expectations for cleaning a room are well laid out. Strongly disagree Strongly
agree 1 2 3 4 5 6
3. There is enough education about cleaning a room. Strongly disagree Strongly
agree 1 2 3 4 5 6
4. I am able to keep up with my workload. Strongly disagree Strongly
agree 1 2 3 4 5 6
5. What is the hardest thing to clean? Why?
6. What is the easiest thing to clean? Why?
7. What surfaces of the room do you think the patient, visitors, and medical staff touch the most？
8. What would make your job easier?
9. If you could change one aspect of your job, what would it be?
10. Other Comments:
Thank you for your time!
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Appendix C: Telephoned Hospital Questions
Preface: The purpose of these questions is to assist the students in gaining a better understanding of the various monitoring processes that are being implemented at other hospitals nationwide. This input will be used to develop reasonable recommendations for IOE 481 senior design project.
1. Do you have a standardized discharge cleaning procedure?
2. How are custodians notified when a room needs to be cleaned?
3. How do custodians identify what surfaces of the room to clean?
4. How is the performance of the custodial staff measured?
5. Do you have a working standardized monitoring process to identify cleanliness of rooms upon patient discharge?
6. Do you use a quality metric to measure performance annually/monthly/weekly/daily?
7. Have you heard of the Black-light germ surrogate studies being conducted?
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Appendix D: Literature Research References
1. Eric R. Goodman, BS; Richard Platt, MD, MS; Richard Bass, BS, CHESP; Andrew B. Onderdonk, PhD; Deborah S. Yokoe, MD, MPH; Susan S. Huang, MD MPH Impact of an Environmental Cleaning Intervention on the Presence of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on Surfaces in Intensive Care Unit Rooms
Infection Control and Hospital Epidemiology, July 2008, Vol. 29, No. 7
2. Erik R. Dubberke, MD et al Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals
Infection Control and Hospital Epidemiology, October 2009, Vol. 29, Supplement 1
3. Philip C. Carling, MD et al Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals
Infection Control and Hospital Epidemiology, November 2008, Vol. 29, No.11
4. Philip C. Carling, MD et al An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology
American Journal of Infection Control, October 2006, Vol.34, No. 8
5. John Leander Po, MD, PhD, Robert Burke, RN, CIC, Carol Sulis, MD, and Philip C. Carling, MD Boston, Massachusetts
Dangerous cows: An analysis of disinfection cleaning of computer keyboards on wheels
American Journal of Infection Control, November 2009, Vol.37, No. 9
6. Philip C. Carling, Janet L. Briggs, Jeanette Perkins and Deborah Highlander Improved Cleaning of Patient Rooms Using a New Targeting Method
CID 2006:42 (1 February) • BRIEF REPORT
7. C.J. Griffith , P. Obee , R.A. Cooper , N.F. Burton , M. Lewis The effectiveness of existing and modified cleaning regimens in a Welsh hospital
Journal of Hospital Infection (2007) 66, 352-359
8. Julie E. Williamson Dishing the dirt on common cleaning oversights
Healthcare Purchasing News, October 2009
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9. Reno Minimal Time Guidelines for Patient Room Occupied and Terminal (Discharge or Transfer) Cleaning and Disinfecting
The American Society for Healthcare Environmental Services (ASHES), September 24 2009
10. Margaret Schellen, Kyle Cassling, Dr. Mark Rupp, Ann Adler, and Teri Fitzgerald Cleanliness and Disinfection of Patient Rooms and its Correlation with Healthcare-Associated Infections
University of Nebraska Medical Center and Nebraska Medical Center, Omaha, NE
11. Paul Turner Inpatient Critical Areas Performance Improvement Plan
University of Nebraska Medical Center and Nebraska Medical Center, Omaha, NE
12. Ecolab Healthcare Focuses on Infection Control and Environmental Cleanliness at APIC Annual Conference Biotech Week June 24, 2009, p3531
13. Ecolab Inks Licensing Pact with Dr. Philip Carling Health & Beauty Close-Up August 26, 2009, pNA
14. Ecolab Licenses Environmental Hygiene Application from Infection Control Expert Dr. Philip Carling Biotech Week Sept 9, 2009, p2914
15. William A. Rutala, Ph.D., M.P.H. Clostridium difficile: What Antiseptics and Disinfectants Should We Use?
disinfectionandsterilization.org
16. B. Hota*, D.W. Blom, E.A. Lyle, R.A. Weinstein, M.K. Hayden Interventional evaluation of environmental contamination by vancomycin-resistant enterococci: failure of personnel, product, or procedure?
Journal of Hospital Infection (2009) 71, 123-131
17. John M. Boyce Environmental contamination makes an important contribution to hospital infection
Journal of Hospital Infection (2007) 65(S2) 50–54
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18. Milt Hinsch C.diff Run, C.diff Spread, Stop C.diff! (A Clostridium difficile primer for infection preventionists)
Managing Infection Control, October 2009, Volume 9, Issue 10
19. University of Michigan Hospitals and Health Centers Environmental Services Cleaning Procedures
20. Gina Rollins Wiping Out Infections or 2009 Infection Prevention & Hospital Cleaning Survey
Materials Management In Health Care, May 2009, Vol. 18, No. 5
21. Bob Kehoe Battling H1N1
Materials Management In Health Care, December 2009, Vol. 18, No. 12
22. Jennifer Blue, BSc, RRT, RPsgT,CIC et al Use of a fluorescent chemical as a quality indicator for a hospital cleaning program
The Canadian Journal of Infection Control, Winter 2008, Vol.23, No.4
23. S.J. Dancer How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in Hospitals
The Journal of Hospital Infection-Volume 56, Issue 1
24. C.J.Griffith; R.A. Cooper; C.Davies; J.Gilmore; M. Lewis An evaluation of hospital cleaning regimes and standards
The Journal of Hospital Infection-Volume 45, Issue 1 (May 2000)
