Assessment of hospital daily cleaning practices using ATP bioluminescence in a developing country

braz j infect dis.2014;18(6):675–677

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

Brief

Communication

Assessment

of

hospital

daily

cleaning

practices

using

ATP

bioluminescence

in

a

developing

country

Alejandra

A.

Zambrano

_,

_Alex

_Jones

_,

_Paula

_Otero

_,

_Maria

_Cristina

_Ajenjo

_,

Jaime

A.

Labarca

a_{InfectionPreventionandControlCommittee,HospitalClínicoyClínicaUCLira,ReddeSalud,UC-CHRISTUS,Santiago,Chile} b_{DepartmentofInfectiousDiseases,SchoolofMedicine,PontificiaUniversidadCatólicadeChile,Santiago,Chile}

c_{UniversidadPeruanaCayetanoHeredia,Peru}

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Articlehistory:

Received16April2014 Accepted3June2014

Availableonline1September2014

Keywords: ATPbioluminescence Cleaning Bacterialresistance Nosocomialinfections

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Visualassessmentofsurfacesmaynotbeenoughtodocumentthelevelofcleanlinessinthe hospitalsetting.Itisnecessarytointroducequantitativemethodstodocumenttheresults ofthispractice.

Objective:Toevaluatetheefficacyofhospitalterminalcleaningprocedures,usingan adeno-sinetriphosphate(ATP)bioluminescencemethodinateachinghospital.

Method:During2008weconductedanevaluationusingATPbioluminescenceLIGHTNING MVPTM_{(Arquimed)ofexternalandinternalhousekeepingservice.Afterconductingan} ini-tialevaluationweimplementededucationofcleaningpracticesandfinallywedidapost interventionevaluation.Usingchi-squaremethodwecomparedpriorversusaftercleaning, qualityofcleaningperformedbyexternalversusinternalpersonnel,singleversusdouble terminalcleaningproceduresandpriorversusafterintervention.AfindingofthreeRLUor lesswasconsideredacleansurface.

Results:Weperformed198evaluationsin33patientunitsandnineOR.Internalpersonnel accomplished 25.37%ofclean surfacesbeforeand80%aftertheeducationintervention (p=0.01).Incontrast,externalpersonnelobtained68.8%beforeand73.33%afterintervention (p=0.3).

Conclusions: Thisstudysuggeststhatvisualassessmentisnotenoughtoensurequalityof theprocessanditisnecessarytodocumentthelevelofcleanlinessbyquantitativemethods. ©2014ElsevierEditoraLtda.Allrightsreserved.

∗ _{Correspondingauthorat:DepartmentofInfectiousDiseases,EscueladeMedicina,PontificiaUniversidadCatólicadeChile,Santiago,} Chile.

E-mailaddress:jlabarca@med.puc.cl(J.A.Labarca).

http://dx.doi.org/10.1016/j.bjid.2014.06.008

676

Highquality cleaning ina hospitalenvironment ispart ofimportantmeasurestopreventthespreadof healthcare-associatedpathogens.Touchingcontaminatedenvironmental surfacesmayresultintheacquisitionofpathogensonhands.1 TheguidelinesforHandHygieneinHealth-CareSettingshas thereforerecommendedhealthcareworkersroutinely disin-fectingtheirhandsaftercontactwithobjectsintheimmediate environmentofallpatients.1_{Manystudieshaveprovedthat} cleaningpracticesareoftensuboptimalandtheenvironment may remain contaminated aftercleaning.2,3 _Visual assess-ment of surfaces has proved to be unreliable to control cleaning.Thereforeitisnecessarytointroducequantitative methodsto documentthe resultsofthis practice. Measur-ingresidualadenosinetriphosphate(ATP),presentinthecells ofallliveorganisms,makesitanidealbiomarkerof micro-bialcontaminantsandcouldbeusedastooltoevaluatethe cleaningproceduresinsidethehospitals.

Theaimofthisstudywastoassessthequalityofhospital terminalcleaningproceduresusingATPbioluminescencein differentsituationsinordertoimproveourcleaningprotocols.

Methods

Ourinstitutionisa500-bedteachinghospital.Cleaning proce-dureswereperformedbytwodifferenthousekeepingservices, anexternalprivatecleaningcompanyandinternalhospital staff.Both groups followed the same hospital policiesand weresupervisedbythesamegroupofregisterednursesand generalservicesmanagers. Patientunitswerecleanedwith quaternaryammonium,exceptwhenpatientshada Clostrid-iumdifficileassociateddiarrhea.Inthiscase,chlorine5000ppm concentrationwasusedtocleantheunits.

ToevaluatethequalityofthecleaningprocessATP biolumi-nescenceLIGHTNINGMVPTM_{(Arquimed)wasused.Sampling}

andprocessingwasdonefollowingthemanufacturer’s rec-ommendations.Thesurfacewasconsideredcleanwhenthe resultofmeasurementwasbelowthecut-offofthreerelative lightsunits(RLU).4

Inthefirstphaseofthestudy,housekeeperswerenot noti-fiedthatmonitoringofcleaningwasbeingconducted.Then, inthesecondphaseofthestudy,weimplementedan inter-ventionbasedmainlyineducationandthehousekeepingstaff wasinformedthattheyweregoingtobemonitored.

Usingchi-squaremethodwecomparedRLUresultsbefore andaftercleaning;singleanddoubleterminalcleaning proce-dures;internalversusexternalstaff,andfinallywecompared the results before and after the intervention was imple-mented.

Results

Weperformed198evaluationsin33patientunitsandnine operatingrooms before and afterterminalcleaning during 2008.Beforeinterventiononly61/137(44.53%)surfaceswere consideredcleanaccordingtothebioluminescencemethod. Onceinterventionwascompleted15/20(75%)surfaceswere clean(p=0.01).Beforeintervention,cleaningwassatisfactory in 17/67 (25.37%) done byinternal personnel and in48/70 (68.8%)surfacesperformedbyexternalpersonnel(p<0.001).

After intervention internal personnel accomplished clean-ingsatisfactoryin4/5(80%)surfaces(p=0.01),whileexternal personnelachieved11/15(73.33%)cleansurfaceswithno sta-tisticaldifference(p=0.44).Singleterminalcleaningshowed RLU<3in31/53 (58.49%) ofsurfaces incontrast with13/17 (76.47%)withdoubleterminalcleaning.However,resultswere notsignificantlydifferent(p=0.18).

Discussion

Contaminatedenvironmentalsurfacesplayanimportantrole intransmissionofhealthcare-associatedpathogens.1,3 Expo-suretoacontaminatedenvironmenthasshowntobearisk factorfortheacquisitionofvancomycin-resistantEnterococcus

(VRE),methicillin-resistantStaphylococcusaureus(MRSA)and

Acinetobacterbaumannii.5

Ithasbeenprovedthatenforcingroutineenvironmental cleaningmeasuresisassociatedwithdecreasedVRE contam-inationonsurfacesandhealthcareworkershands,andalso with asignificant reductionin VREcross-transmission.2 _In the caseofMRSAithasbeenobservedthatitisfrequently identifiedonhands ofinvestigatorsaftercontactwith con-taminatedobjects fromthepatient’s environmentandcare equipment.Highenvironmentalcleaningstandardsplayan important role in controlling outbreaks of A. baumannii in intensivecareunits,andenvironmentaldecontaminationhas beenassociatedwithreductionsofC.difficileinfection.5

Inthisstudyweaimedtosupportthatitisnecessaryto introducequantifiablemethodstoensurethequality clean-linesslevels.Ausefulmethodisenvironmentalculturethat allowsidentifyingtheorganismanditssusceptibility,but it istime-consuminganddependsontheorganism’sviability, adequatetransportation,andthecostsarehigh.These limi-tationsdonotallowenvironmentalculturestobeusedindaily work.

ATPbioluminescenceLIGHTNINGMVPTMassesses clean-ingeffectivenessinrealtimeindicatingtroublespots,making possibletoimprovetheprocess.But,thistechniquehassome limitationssuchasimpossibilitytoidentifytheorganismand no direct relationbetween RLU and bacterial load. Results depend on time between sanitation and bioluminescence measurement (ATP disappears within 2h of living matter death)andhighcostofimplementationforsomeinstitutions.4 Using thismethodwedemonstratedthat theefficacyof cleaningwasnotasexpected.Only25.37%ofsurfacescleaned byinternalpersonneland68.8%ofsurfacescleanedby exter-nal personnelwere considered clean bythis method. This correlateswithBoyceetal.4_{whoalsousedATP} biolumines-cenceandfoundthataftercleaning24%ofthesurfacesamples were stillcontaminatedwithMRSAand16%ofthesurface samplesstillyieldedVRE.

Ourresultssupportthataninterventionincluding educa-tion and monitoring improves the quality ofcleaning.The internal personnel improved from 25.37% to 80% (p=0.01), whileexternalpersonnelimprovedfrom68.8%to73.33% with-out significantdifferenceforbothperiods(p=0.44).Wealso didnotfindasignificantdifferencebetweensingleanddouble terminalcleaning.

brazj infect dis.2014;18(6):675–677

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Sincethiswasanevaluationofaroutinepracticerather than a randomized trial, healthcare workers could make improvementsjustbecausetheyknewtheywouldbe mon-itored. In addition, samples were too small and with size differences before and after intervention. Finally, only one hospitalwasincluded,soourfindingsmaynotbeapplicable toallinstitutions.

Inconclusion,visualassessmentisnotenoughtoensure thequalityofthecleaningprocessanditisnecessaryto doc-umentthelevelofcleanlinessbyquantitativemethods.This studyusedATPbioluminescencetodemonstratetheadequacy ofcleaning practices,and the impact ofeducational inter-vention.WerecommendtheuseofATPbioluminescenceto controlthecleaningofhospitalenvironmentassociatedwith feedbackandeducationinordertoimprovecleaninginthe hospitalsettings.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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