Variations in Hospital Daily Cleaning Practices • Author(s): John M. Boyce, MD; Nancy L. Havill, MT; Abigail Lipka; Heather Havill;Ramo Rizvani, BSSource: Infection Control and Hospital Epidemiology, Vol. 31, No. 1 (January 2010), pp. 99-101Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/649225 .

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infection control and hospital epidemiology january 2010, vol. 31, no. 1

c o n c i s e c o m m u n i c a t i o n

Variations in Hospital Daily CleaningPractices

John M. Boyce, MD; Nancy L. Havill, MT; Abigail Lipka;Heather Havill; Ramo Rizvani, BS

Prospective observations and adenosine triphosphate biolumines-cence assays were used to evaluate daily cleaning practices in a uni-versity-affiliated hospital. Substantial variations were found in theamount of time spent cleaning high-touch surfaces, in the numberof disinfectant wipes used in each room, and in the level of clean-liness achieved by housekeepers.

Infect Control Hosp Epidemiol 2010; 31:99-101

Contaminated environmental surfaces in healthcare facilitiescan contribute to the transmission of healthcare-associatedpathogens.1-4 Improved cleaning and disinfection of the en-vironment has been shown to reduce transmission of path-ogens.3,5 Although cleaning of environmental surfaces in hos-pitals has been demonstrated to be suboptimal,3,6-9 there arefew quantitative data regarding the variations in cleanlinessof environmental surfaces achieved by housekeepers respon-sible for daily cleaning of patient rooms. We used direct ob-servation and an adenosine triphosphate (ATP) biolumines-cence assay to monitor variations in daily cleaning practicesby housekeepers and to assess the level of cleanliness of sur-faces after daily room cleaning.

methods

A prospective study was conducted in a 500-bed university-affiliated hospital. Routine daily cleaning was performed byusing wipes soaked with a quaternary ammonium disinfectant(Virex II 256; JohnsonDiversey).

Two individuals notified 7 housekeepers that they wouldbe observed while performing daily cleaning and that 5 high-touch surfaces in each room would be assessed for cleanlinessafter cleaning. We selected housekeepers who were believedto employ a good cleaning technique, so that we could de-termine how often ATP readings after cleaning met a pro-posed cutoff value for defining surfaces as “clean” in health-care settings.10 Observations were made from a conveniencesample of 62 patient rooms. The identity of the housekeeperand the amount of time spent cleaning high-touch surfaceswere recorded. The surfaces sampled included bedside rails,overbed tables, television remote controls, bathroom grabbars, and toilet seats.1,2,4,9 The order in which surfaces were

cleaned and the number of disinfectant wipes used were re-corded prospectively in the last 14 rooms included in ourstudy.

After surfaces had been allowed to dry for at least 10 minutes,a defined area of each surface was sampled with an ATP bi-oluminescence assay (Clean-Trace ATP System; 3M), as de-scribed elsewhere.9 Surfaces that are relatively free of excretions,secretions, food, or other organic substances (which containATP) yield low relative light units (RLUs), whereas contami-nated surfaces yield high RLUs. Because of variations in thesize and shape of the items sampled, we did not use a templateto sample the same size area of each surface. Median RLUvalues and times spent cleaning surfaces were calculated foreach of the 5 high-touch surfaces. Median RLU values werecalculated for 4 of the 7 housekeepers who cleaned at least 8rooms. The proportion of surfaces that yielded ATP read-ings less than the proposed cutoff value of 250 RLUs wascalculated.10

The RLU values and times spent cleaning for the 5 high-touch surfaces were compared using the Kruskal-Wallis 1-way analysis-of-variance test, and ATP readings obtained inrooms cleaned with 2 disinfectant wipes were compared withthose cleaned with 3 or more wipes, by use of the Mann-Whitney U test. Differences in proportions were comparedby use of the x2 test.

results

The number of rooms in which housekeepers were observedwas as follows: housekeeper A, 22 rooms; housekeeper B, 15rooms; housekeeper C, 8 rooms; housekeeper D, 8 rooms;housekeeper E, 3 rooms; housekeeper F, 3 rooms; and house-keeper G, 3 rooms. Median cleaning times for the high-touchsurfaces were as follows: bedside rails, 86 seconds (range, 22–250 seconds); overbed tables, 66 seconds (range, 10–186 sec-onds); television remote controls, 12 seconds (range, 1–43seconds); bathroom grab bars, 22 seconds (range, 2–57 sec-onds); and toilet seats, 75 seconds (range, 20–292 seconds)( ).P ! .001

ATP readings were obtained in 61 of the 62 rooms. Themedian RLU values for the 5 high-touch surfaces varied sig-nificantly, with bedside rails having the highest median RLUvalue and overbed tables the lowest ( ) (Table 1). TheP ! .001median RLU values achieved by the 4 housekeepers whocleaned at least 8 rooms (ie, housekeepers A–D) varied con-siderably, as shown in Figure 1.

The proportion of surfaces that yielded ATP readings ofless than 250 RLUs after daily cleaning varied significantly:40 (66%) of 61 bathroom grab bars, 41 (71%) of 58 bedsiderails, 44 (79%) of 56 television remote controls, 49 (84%) of

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100 infection control and hospital epidemiology january 2010, vol. 31, no. 1

table 1. Adenosine Triphosphate (ATP) Readings Observed byMeans of Bioluminescence Assay on 5 High-Touch Surfaces afterDaily Cleaning in 61 Patient Rooms

Surface sample Median RLU values (range)

Bedside rails (n p 58) 174 (5–4,039)Bathroom grab bars (n p 61) 152 (8–1,442)Television remote controls (n p 56) 92.5 (9–2,030)Toilet seats (n p 61) 49 (11–1,133)Overbed tables (n p 58) 33 (4–15,400)

note. RLU, relative light unit.

figure 1. Bar graph of median adenosine triphosphate readings,expressed as relative light units, from 5 high-touch surfaces cleanedby housekeepers A–D.

58 overbed tables, and 52 (85%) of 61 toilet seats ( ).P p .04The proportion of surfaces that yielded ATP readings of lessthan 250 RLUs varied significantly among the 4 housekeeperswho cleaned at least 8 rooms: 88 (81%) of 108 surfacescleaned by housekeeper A, 61 (86%) of 71 surfaces cleanedby housekeeper B, 25 (71%) of 35 surfaces cleaned by house-keeper C, and 17 (55%) of 31 surfaces cleaned by housekeeperD ( ).P p .003

In the 14 patient rooms for which additional observationswere performed, the number of disinfectant wipes used ineach room varied as follows: 1 wipe in 1 room, 2 wipes in 5rooms, 3 wipes in 6 rooms, 4 wipes in 1 room, and 5 wipesin 1 room. The first surface cleaned was the bedside rail in3 rooms, the overbed table in 1 room, the television remotecontrol in 2 rooms, the bathroom grab bar in 4 rooms, andthe toilet seat in 4 rooms.

ATP readings were available for 13 of the 14 rooms forwhich additional observations were performed. The medianRLU values in 5 rooms cleaned with only 2 disinfectant wipeswere higher than those obtained in the 8 rooms cleaned with3, 4, or 5 wipes for 4 of the 5 high-touch surfaces: bedsiderails (416 vs 204 RLUs; ), overbed tables (2,046 vsP p .6232.5 RLUs; ), television remote controls (144 vs 73.5P p .048RLUs; ), bathroom grab bars (121 vs 233.5 RLUs;P p .72

), and toilet seats (179 vs 134 RLUs; ).P p .17 P p .46

discussion

The prospective observations and quantitative assay systemused in our study revealed substantial variations in the tech-nique used by housekeepers during daily cleaning of patientrooms and in the level of cleanliness of high-touch surfacesafter cleaning was performed. The differences in the timespent cleaning the 5 high-touch surfaces are due in part tothe differences in the size of the objects being cleaned. Ofgreater concern was the wide variation in the time spentcleaning a given type of surface. Factors that may have in-fluenced cleaning times include whether surfaces looked dirtyand housekeeper attitudes regarding which objects are themost likely to be contaminated (eg, toilet seats). The numberof disinfectant wipes used in each room also varied substan-tially. We also found that smooth surfaces (eg, overbed tablesand toilet seats) were cleaned more thoroughly than roughor irregular surfaces, a finding consistent with previous qual-itative studies of cleaning performance.8

Because ATP readings before cleaning were not measured,we were unable to establish the magnitude of reductions inthe RLU values achieved after cleaning. However, a recentstudy conducted in our institution revealed that the medianRLU values were significantly lower after daily cleaning thanbefore cleaning.9

Limitations of our study include the investigation of onlya single hospital, the small number of housekeepers included,and the small number of rooms in which the number ofdisinfectant wipes used per room was recorded. Althoughhousekeepers achieved ATP readings below the proposed cut-off value of less than 250 RLUs for 226 (77%) of 294 high-touch surfaces, it is difficult to compare our results with thoseof other studies because there are no standardized criteria forclassifying surfaces as clean in healthcare facilities.

Our findings suggest that a number of variables need tobe considered when assessing hospital cleaning practices andthat providing housekeepers with continuing education andfeedback is necessary to achieve compliance with recom-mended daily cleaning practices. Further studies using ATPbioluminescence assays for monitoring hospital cleanlinessare warranted.

acknowledgments

Potential conflicts of interest. J.M.B. reports that he has served on the CloroxScientific Advisory Board; has been a consultant to Bioquell, 3M, AdvancedSterilization Products, Clorox Corporation, GOJO Industries, CardinalHealth, and the Soap and Detergent Association; has received grant supportfrom 3M, GOJO Industries, and Becton-Dickinson; and has received hon-oraria from Advanced Sterilization Products, GOJO Industries, and Becton-Dickinson. All other authors report no conflicts of interest relevant to thisarticle.

From the Infectious Diseases Section (J.M.B., N.L.H., A.L., H.H.) and the

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variations in hospital cleaning practices 101

Environmental Services Department (R.R.), Hospital of Saint Raphael, andthe Yale University School of Medicine (J.M.B.), New Haven, Connecticut.

Address reprint requests to John M. Boyce, MD, Infectious Diseases Sec-tion, Hospital of Saint Raphael, 1450 Chapel Street, New Haven, CT 06511(jboyce@srhs.org).

Presented in part: 19th Annual Scientific Meeting of the Society for Health-care Epidemiology of America; San Diego, California; March 19–22, 2009;abstract 277.

Received June 4, 2009; accepted August 6, 2009; electronically publishedDecember 1, 2009.� 2009 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2010/3101-0018$15.00. DOI: 10.1086/649225

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