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Floor corners, bathroom floors, and ceiling vents are hottest spots for dangerous C. diff spores

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June 1, 2018

Bathroom floors, nurse call buttons, and ceiling vents are among the locations where you will most often find Clostridium difficile spores after both routine and terminal cleaning of patient rooms, a recent study stated.

But the place where C. diff most frequently persists, threatening both patients and staff? Floor corners.

The aforementioned study, which was published last year in the Infection Control & Hospital Epidemiology journal, identified the most common sites where C. diff persists after terminal cleaning and hydrogen peroxide aerial decontamination. C. diff infections are among the most frequently reported healthcare-associated infections (HAIs), affecting around half a million people and contributing to nearly 29,000 deaths every year.

The researchers, using a sponge swab, sampled 16 sites representing “high-frequency contact” or “difficult-to-clean” surfaces in patient isolation rooms or patient bays before terminal cleaning, after terminal cleaning, and after hydrogen peroxide disinfection. The results were used to focus cleaning efforts, the authors wrote.

Of the 2,529 sites from 146 rooms and 44 bays that were sampled over the course of one year, floor corners, at 29%, most frequently came back positive for C. diff spores after disinfection. Bathroom floors and ceiling vents were also areas of particular concern among the surfaces in patient rooms and bathrooms the researchers studied. That list included, but was not limited to, bedside tables, trash bin lids, door handles, toilet assist bars, toilet seats, sink fixture handles, and bathroom door handles.

Overall, C. diff spores were found on 22.9% of the sites in patient isolation rooms or patient bays they sampled before terminal cleaning, on 10.6% after terminal cleaning, and on 4.4% after hydrogen peroxide disinfection.

“We were surprised at the high levels of spores in the environment — most, presumably, from asymptomatic carriers in the patient population,” one of the study’s authors, Peter Wilson, MA, MD, FRCP, FRCPath, of University College London Hospitals, told Health Facilities Management. “Some even remained after hydrogen peroxide, emphasizing the importance of a good terminal clean.”

The researchers wrote that manual cleaning "was often insufficient" when attempting to remove C. diff from the environment. Identifying these highly contaminated sites did lead to a gradual decline in C. diff following hydrogen peroxide disinfection. They added that "removal of soil was important in improving the long-term efficacy of hydrogen peroxide decontamination with the aim of reducing the risk of transmission.”

According to Mayo Clinic, C. diff is a bacterium that “can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.” Illness from C. diff most commonly affects older adults in hospitals, long-term care facilities, or other healthcare facilities. Mayo Clinic said it “typically occurs after use of antibiotic medications” but that studies show increasing rates among “people not considered high risk, such as younger and healthy individuals without a history of antibiotic use or exposure to healthcare facilities.”

“Recent evidence suggests the environment is the most important source of [healthcare-associated] Clostridium difficile, particularly for highly susceptible patients,” Wilson told Health Facilities Management. “Spores of this organism can resist disinfectants or areas may be missed by cleaners. Reducing the load in the hospital environment has been found to reduce the number of patients becoming infected.”

Sentara’s successful five-step plan
Those looking to establish consistent cleaning and disinfection protocols to combat C. diff and other infectious disease can copy the playbook of Sentara Healthcare, a Norfolk, Virginia–based health system made up of several hospitals, assisted living centers, hospices, and nursing homes.

In 2015, Sentara kicked off a project to gauge how well it was cleaning patient rooms, determine best practices for environmental services departments (ESD) to reduce C. diff transmission, and ensure each room was disinfected the same way each time.

To meet those goals, Sentara gathered a multidisciplinary team to create a five-step program that included structured interviews, a systemwide summit, education and training, competency audits, and universal checklists. Using this process, Sentara reduced the number of annual C. diff cases from 368 to 267 between 2015 and 2017. That’s a 27% drop in infections in just two years.

“The process was new because it was the first time we really pulled everyone together to address room cleaning across our system of 12 hospitals,” says Linda Estep, BS, MT (ASCP), CIC, a Sentara Healthcare system manager of infection prevention and control.

Structured interviews
Joani Brough, RN, NE-BC, is vice president and nurse executive of Sentara Princess Anne Hospital in Virginia Beach, Virginia. She told Health Facilities Management that Sentara’s first step was researching best practices and expert opinions on patient room cleaning. With that, the team came up with interview questions for their ESD managers.

“The questions focused on education and training; logistics; and cleaning of occupied, discharged, and isolation rooms,” said Brough. “The ESD managers of the system’s 12 hospitals were asked to submit copies of their current policies and procedures for cleaning occupied and discharged patient rooms and to provide audit processes.”

These in-depth interviews took between 30 and 45 minutes. After comparing the transcripts, the team found noticeable variation in how each facility handled room cleaning.

For example, Estep says they learned that many cleaning products and ESD training processes were in use across the system. There was no standardized definition of a “high-touch” surface. Finding the time needed to correctly clean a room was a challenge during periods of high patient volume. Cleaning of an occupied room was not standardized.

The only two things that were uniform across all facilities were the first and last steps for cleaning an occupied room. All ESD managers said that greeting patients should be the first step, while the last should be asking patients if there’s anything they need.

During the interviews with ESD managers, Sentara discovered a few barriers to the cleaning process, including family and staff in the room delaying the cleaning, communication breakdowns such as lack of notification and excessive documentation, and personal items and medical equipment cluttering the room.

“It was clear from the structured interviews that several opportunities existed to improve standardization for processes and products across all facilities,” Brough wrote. “These included education and training for new employees, annual competency and audit requirements, universal checklists, and assignment sheets and elimination of cloth cubicle curtains.”

Systemwide summit
After the interviews, Sentara hosted a systemwide summit with its stakeholders. ESD managers, infection control officers, and nursing leaders worked out an agreement on room cleaning, along with a reward system for compliance.

“Including [stakeholders] is key,” says Estep, “[as is] recognizing their critical role in patient safety.”

“One of the main focuses was to make it easy for the staff to do the right things and difficult for them to do the wrong things,” Brough wrote. “For example, pictures of the high-touch areas were taken and made into a card, which was placed on the cleaning cart to remind staff of what is considered to be a high-touch surface.”

After the summit, three policies were updated: cleaning an occupied room, cleaning an empty room, and cleaning cubicle curtains.

“Each policy was detailed on the required action steps to standardize the procedure,” Brough wrote. “For instance, the cleaning of an occupied isolation patient room contained 23 steps and supplemental guidance. Cleaning a discharged patient room had 28 steps. Bleach wipes were to be used for all surfaces, and no microfiber cloths were to be used.”

Education and training
After the new policies were made, Sentara then had to reeducate its staff. To do so, it created a C. diff–specific eLearning module. This module was made available 24/7 for staff convenience, and managers had the ability to see whether their staff had gone through the module.

“Video format was used to demonstrate appropriate handwashing techniques, isolation precautions, customer service and patient interaction, and donning and doffing personal protective equipment,” Brough wrote. “Assessments were incorporated into the module to evaluate the employee’s acquisition of new knowledge.”

When new employees are hired, they’re given standardized job aids as part of their onboarding process. For example, they get a visual guide of all 17 high-touch areas.

“Budget issues and costs [for the program were] offset by cost avoidance of HAIs,” says Estep. “[And] leadership supported the cost and [common] sense that HAI prevention makes.”

Competency and checklists
Steps four and five of the project were annual competency audits and creating universal checklists. Sentara made a standardized process for auditing the cleaning done on the 17 high-touch areas.

“Within discharged rooms, 30% of the surfaces (five surfaces per discharged room) are audited on a weekly basis, and data are collected by infection prevention and control professionals,” wrote Brough. “Adenosine triphosphate assays are used, results are reported monthly, and feedback is given to staff.”

The final step was creating standardized cleaning checklists that mirrored the updated policies. Each one gives step-by-step instructions for each task, including which products to use for each. Laminated copies of the checklist were placed on each cleaning cart for quick reference.




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