WIPE OUT Do your staffers remember to disinfect the surfaces that are used so often they're overlooked?

Do you enter a room that's been turned over after a patient's discharge or a case's conclusion and determine if it's clean or dirty by sight? If you don't see debris or fluid, the room is ready to go, right? But you have no way of knowing how effectively microbes have been eliminated. Auditing how well your rooms are actually getting cleaned would offer peace of mind that they're safe for patients and surgery, validate environmental services' role in keeping infection rates in check, and suggest opportunities for improvement in practice or staffing.

KEYS TO CLEAN Non-critical surfaces don't need to be sterilized, but as high-touch surfaces, they can still cross-contaminate.

Detecting what you can't see
High-touch areas such as OR tabletops, stands, door handles, stretcher side-rails, over-bed tables and other equipment and fixtures in the clinical environment typically only make contact with intact skin. They don't tend to touch mucous membranes or penetrate the skin, so they're not a huge risk for transmitting healthcare-associated infections. As a result, they're considered non-critical surfaces in the spectrum of disinfection and sterilization requirements. That doesn't exempt them from cleaning against the possibility of cross-contamination between patients and staff, though. While the CDC's "Guideline for Disinfection and Sterilization in Healthcare Facilities" admits there's not much data to back up surface disinfection's effect on infection rates, the agency and OSHA advise the cleaning and disinfection of potentially contaminated surfaces.

Visual observations wouldn't detect surface contaminants, measure disinfection's effectiveness, or give you hard facts to act on. To conduct your QI study, consider a technological solution to help you detect what's invisible to the eye. Several detection systems on the market can assist on this front — each with its own pros and cons, so trialing is essential to making a choice that will work in your facility and perioperative process.

One of the systems we trialed involved swabbing a site before it was cleaned, then returning afterward with an ultraviolet light to examine the area that was swabbed and assess the thoroughness of the cleaning. But, at our facility, rooms get turned over fairly quickly. It wasn't realistic to expect that a supervisor could get to the room before housekeeping to apply the swab, or wait more time to return for the review. (We'd also heard stories from our peers about housekeepers who brought their own lights to make sure their work included the right spot.)

We wanted a simple solution that wouldn't delay turnovers or patient throughput. The system we chose only required us to swab after cleaning to find out how much of a bioload remained there. It works by collecting adenosine tri-phosphate (ATP), a compound found in all organic matter. You swab anywhere in a room, slide the swab into a reader that uses the bioluminescence of ATP to detect the presence of organic matter on a swabbed surface, and 30 seconds later it tells you how much of it is there. It gives the result as a number: If it's below 500, the swabbed area has passed the test. From 500 to 1,000 is "caution," and more than 1,000 is "fail." The collected tests can be downloaded from the reader into a database that tracks and tabulates the results to show how often we're successful in disinfecting which surfaces.

Put to the test
We started swabbing in September 2012, testing patient rooms after discharges and after housekeeping had given them a good once-over with quaternary ammonia and cloths. We chose 6 high-touch areas in each room, the same ones each time, which we'd picked based on the frequency of use: the doorknob, the light switch, a bed side-rail, the over-bed table, the call button and the television remote control.

Our aim was to conduct 300 random swabs a month. Our housekeepers don't know which rooms we'll be checking, and we can change the sites we swab if we should find we're always getting the same successful results.

In February, we began swabbing in our ORs, too. It's always been our plan to expand the testing to other areas of the hospital, and we've been prioritizing the places that present the highest infection risks.

In the ORs, we check the center of the surgical table, certain designated stands and sterile tables, a kick bucket, the light switch and the door handle. We report those numbers separately to our surgical personnel, but we also combine them with the patient rooms data for a hospital-wide overview in our monthly reports to the infection control committee.

At the outset, our employees were afraid that this testing was going to lead to immediate discipline. We explained that we weren't out to discipline, just to educate, and they've been very receptive to the idea. When they see us coming with the machine, they want to join us in the room and watch the swabbing to see what their numbers are.

Quality, improved
The object of any quality improvement project is to collect baseline data, conduct a program of training, gather continuing data to determine the effectiveness of the training, then administer retraining as necessary to foster further improvements. Ideally, you'll discover some surprises and develop additional applications along the way.

Each month, we've seen the success rate rise. In our initial round of tests in September 2012, we did 102 swabs and saw 61 of them (59.8%) pass. In March, after 312 swabs, 217 (69.6%) passed, representing a decline in the number of cautions and fails. Obviously, we'd like to reach 100% passing, but in the meantime we've learned a lot about the strengths and shortcomings in our surface disinfection practices. For example: Although we are really good at smooth surfaces such as door handles — 1 wipe and you're done — bedrails are harder to handle. They're not smooth, they're rough and porous, and we have to really work at them.

Our housekeepers do a very good job, but we were surprised at how well they cleaned the over-bed tables. We don't swab those on their top surfaces, but underneath, where contaminated fingers pull and push them around. (The detection system's product representatives recommended particularly effective places to swab.) We didn't expect they'd reach that site so routinely.

If our tests turn up failure numbers, we ask the housekeeping employee who cleaned the room to return and fix the problem. (If the housekeeper has already left for the day when we make the discovery, we ask another staffer to help out.) If we notice that an employee's rooms consistently get caution or failure numbers, we'll review their cleaning methods with them.

We've even used this microbial detection technology to enact changes outside of our study. We've used it to train nurses how to clean their work spaces, the nurses' station counters, computer workstations, handheld phones and other things they're responsible for cleaning at the beginning of every day, that may have been routinely overlooked. We swabbed liberally and showed them how high the number was. After they re-cleaned, we received a much lower number.

Whole room solutions?
The quality improvement study as we planned and conducted it observed surface disinfection by manual means. We're all curious to see the effects that automated, mechanical disinfection might have on the results.

We've been trialing systems that use ultraviolet light or hydrogen peroxide to disinfect a whole room at a time, for use in periodic terminal cleaning in addition to our routine by-hand cleaning. They each take a different amount of time to operate — the UV takes less than an hour, while the hydrogen peroxide takes several hours — and as always, cost is a factor to consider. But they all seem equally effective in carrying out the job, as evidenced by the swabbings our infection control team performed in the room before and after they were set to work.