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Terminal cleaning beyond 25 minutes does not improve disinfection
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Spending more than 25 minutes on terminal cleaning does not improve disinfection of high-touch surfaces in patient rooms when appropriate disinfectants are used and the environmental management services, or EVS, staff are trained properly, according to results from a single-center trial.
“Appropriate disinfectant choice, proper training of EVS staff and paying attention to contact time are more important,” Chetan Jinadatha, MD, MPH, chief of infectious diseases at central Texas Veterans Health Care System and an associate professor of medicine at Texas A&M Health Science Center, told Infectious Disease News.
Writing in Infection Control & Hospital Epidemiology, Jindatha and colleagues noted that terminal room cleaning should take between 20 to 45 minutes, according to recommendations made by the Association for the Health Care Environment. But they said the recommendation had not previously been “validated for impact on microbial load.”
Their single-center trial was conducted at an acute-care VA hospital in Temple, Texas. The researchers assessed single-occupancy rooms that were previously occupied for at least 48 hours before patient discharge, and collected aerobic bacterial colony (ABC) samples before and after cleaning from five high-touch surfaces, including the bedrail, tray table, call button, toilet seat and bathroom handrail. Cleaning time was measured by a stopwatch and the researchers created three cleaning time groups for the analysis:
- In the limited arm, cleaning was restricted to 25 minutes;
- In the unrestricted-moderate arm, cleaning took less than 45 minutes; and
- In the unrestricted-high arm, cleaning took 45 minutes or more.
According to the study, the limited arm included 225 samples from 45 rooms, the unrestricted-moderate arm included 55 samples from 11 rooms, and the unrestricted-high arm included 170 samples collected from 34 rooms. Even when adjusting for the disinfectant used, surface location and pre-clean ABC counts, Jinadatha and colleagues found that the association between time spent cleaning and ABC counts was “inconclusive.”
Using the limited-time arm as a reference, the estimated incidence rate ratio for the unrestricted-moderate arm was 1.54 (95% uncertainty interval, 0.39-6.67), and it was 2.80 (95% uncertainty interval, 0.92-8.17) in the unrestricted-high arm, Jinadatha and colleagues reported.
They said the findings may not be generalizable to other health care centers, or across pathogens because they “only reported ABC results.”
“Our results suggest that in the presence of appropriate disinfectants and trained EVS staff, the time spent on cleaning beyond 25 minutes may not affect disinfection of high-touch surfaces as assessed by aerobic bacterial colony counts,” Jinadatha said. “If the goal is to achieve disinfection of high-touch surfaces, more than 25 minutes may not make a difference. “
Jindatha also said that “it is likely” the findings of this study will impact future guidelines for environmental cleaning in hospitals. – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Mark E. Rupp, MD
Although counterintuitive, the time spent cleaning a hospital room beyond 25 minutes does not translate into more thorough cleaning. In fact, there is some evidence to suggest that the longer EVS staff take to clean a room, the greater is the post-cleaning bioburden on high-touch surfaces. These were the conclusions of the recently published study by Coppin and colleagues. This is important because pathogens on environmental surfaces can be transmitted to patients and result in health care-associated infections.
ABC counts were measured on five high-touch surfaces (bedrails, call buttons and so on) from 90 rooms before and after terminal cleaning. Rooms were divided into three categories depending upon how much time was spent cleaning: Less than or equal to 25 minutes, 25 to 45 minutes and greater than 45 minutes. Bayesian regression modeling was performed, and there was no conclusive association between time spent cleaning and bioburden, even after adjusting for disinfectant used, surface location and pre-clean bacterial load. Limitations of the study include it being a small, single-center survey and the risk for a significant Hawthorne effect.
These findings were not a surprise because we observed similar results when using a ultraviolet light-tagged marking gel to assess 600 high-touch surfaces in 40 critical care unit rooms cleaned by 24 different housekeepers. In a larger study of 292 hospital rooms, using [adenosine triphosphate] detection to measure cleanliness, we noted there was a subgroup of housekeepers who were able to clean rooms more quickly and more thoroughly than their peers (optimum outliers). Thus, it is not so much about what you clean with (disinfectant choice) or how long you clean, but it is more about how well you educate, train, monitor and manage your housekeepers.
References:
Donskey CJ. Am J Infect Control. 2013;doi:10.1016/j.ajic.2012.12.010.
Rupp ME, et al. Infect Control Hosp Epidemiol. 2013;doi:10.1086/668779.
Rupp ME, et al. Infect Control Hosp Epidemiol. 2016;doi:10.1086/676431.
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