Measuring cleanliness to deliver improvement

It is widely recognised that infection prevention and control is multifactorial, and that the patient environment is a source and reservoir of contamination. A wide variety of equipment is routinely used during the delivery of healthcare and much of it – such as blood-pressure cuffs, commodes, bedpans and pressurerelieving mattresses – are used for multiple patients. The cost of cleaning across the NHS amounts to hundreds of millions of pounds every year, of which most is attributable to labour costs. It is a process that, even today, relies almost entirely on the visual assessment of cleanliness – which is recognised as being of ‘questionable value’. Carling and Bartley,1 for example, found that 89% of hospitals use visual assessment of cleaning that can only detect gross lapses in practice. Only 34%-40% of surfaces are actually cleaned in accordance with hospital policies. They also found that monitoring and interventions can improve the thoroughness of cleaning from 40% to 82%. Effective cleaning can save £56,000 per ward per annum.2 Substantial savings in productivity and effectiveness can be gained by optimising and prioritising the use of available cleaning resources. Objective methods of detection are required for effective inspection. Rapid test systems, such as the use of adenosine triphosphate (ATP) bioluminescence, can provide instant information to enable immediate corrective action and the reduction of risk while providing meaningful quantitative information for management purposes. ATP is the universal energy molecule found in all living cells. The combination of ATP with the enzyme luciferase produces light that can be measured in a luminometer. The amount of light is proportional to the amount of ATP and is expressed in RLUs. The greater the level of ATP, the higher the RLU value, and the dirtier the object being tested. The ATP test has a variety of applications in the healthcare environment, including cleaning verification, hygiene monitoring, and training within housekeeping and infection prevention teams.3-5 Indeed, the revised NHS Cleaning Manual and the Rapid Review Panel recognise the potential role of objective methods of cleaning assessment using ATP bioluminescence, which is now a well established and proven technology. The revised NHS Cleaning Manual6 says that the effectiveness of ATP technology is well validated for the food industry, but evidence of its appropriateness for the different requirements of healthcare settings is not, as yet, extensive. It refers to an evaluation paper from the Department of Health (2007) Evaluation of ATP bioluminescence swabbing as a monitoring and training tool for effective hospital cleaning which concluded that ATP bioluminescence swabbing is a useful indicator of cleanliness in a hospital environment, and may also be useful as an educational tool. The revised NHS Cleaning Manual concluded that there is evidence that ATP cleaning monitors can give an objective measure of how contaminated a surface is, which could indicate how effectively the surface has been cleaned. It recommended the use of ATP cleaning monitors, in addition to existing visual inspection monitoring, to give an indication of the relative performance of cleaning over time using a well planned approach, with consistent sampling points and intervals between tests.

Cwm Taf trial

The infection control team at the Cwm Taf Health Board has conducted a trial to evaluate the use of ATP bioluminescence to provide a rapid objective measurement of cleanliness in the near patient environment of acute hospitals. The team used the SystemSURE Plus ATP Hygiene Monitoring system from Hygiena International to collect and test samples from hand contact surfaces and patient equipment in three different wards in each of two separate acute hospitals within the Cwm Taff Health Board. The SystemSURE Plus requires a swab to be taken of the region to be tested using a sampling device which is then inserted into a hand held instrument. The result is shown within seconds as a number and can be displayed as a simple Pass, Caution or Fail display on the instrument. The trial saw housekeeping teams testing patient tables and wash room areas before and after cleaning in three week blocks over a period of several months. Sample test sites included wash basins, bin lids, toilet seats and flushes, as well as several door handles and push plates. Infection prevention teams similarly tested patient equipment and near patient surfaces in the same wards and over a similar time frame. Sample test sites included nurses call buttons, bed frames, commode seats, bed pan shelves, IV machines, pulse oximeters, and BP machines. The results from ATP measurements are expressed as RLUs which were analysed to determine the levels of background contamination on visibly clean surfaces before and after cleaning. They were also used to compare the effects of cleaning to establish a benchmark for clean surfaces, identify potential areas of concern and compare the results between wards and hospital to look at trends over time. The responses and feedback from users and cleaning staff was also collected.