SummaryThe Louis Stokes Cleveland Veterans Affairs Medical Center tested a multicomponent strategy to improve room cleaning processes, with the aim of reducing the spread of Clostridium difficile infections. The first component involved performance monitoring and feedback to environmental services personnel on the thoroughness of cleaning and disinfecting efforts (aided by use of a fluorescent marker). After 14 months, use of ultraviolet disinfection devices was added at-discharge for cleanings of rooms housing patients with the infection. Four months later, a dedicated team of housekeepers began conducting daily cleaning of these rooms, and supervisors began overseeing the terminal cleaning (still performed by regular housekeeping staff) and formally “clearing” these rooms for the next patient. As a whole, the program significantly improved the thoroughness of room cleanings and reduced the proportion of rooms with positive cultures and the overall health care–associated Clostridium difficile rate, with the bulk of these reductions occurring after introduction of the dedicated housekeeping team. Since the initial study ended, the hospital has scaled back the labor-intensive monitoring and feedback and continues to use the other components as originally implemented.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of CDI rates and key metrics related to the quality of the cleaning and disinfecting process in the rooms of patients with CDIs, including the proportion of high-touch surfaces cleaned and the percentage of such rooms containing positive cultures.
Developing OrganizationsLouis Stokes Cleveland Veterans Affairs Medical Center
Date First Implemented2011
Monitoring and feedback using fluorescent markers began on January 1, 2011; use of the ultraviolet disinfecting device began March 1, 2012; and use of the dedicated team for daily cleanings and the at-discharge room-clearing process commenced July 1, 2012.
Problem AddressedA growing problem, Clostridium difficile infections (CDIs) pose severe health risks for hospitalized patients, including the potential for severe diarrhea, dehydration, sepsis, and, in rare cases, death. The infection spreads relatively easily from patient to patient, and stopping this transmission requires thorough cleaning and disinfecting of environmental surfaces, a process that remains suboptimal in many health care facilities. Several promising strategies have been developed to improve the process, but these strategies remain largely untested in real-world settings.
- A common, growing problem: The number of CDIs has risen significantly since 2000, particularly in hospitalized patients (for whom infection rates grew by approximately 25 percent a year between 2000 and 2003).1 A 2008 study of 648 U.S. hospitals found a prevalence of 13.1 infections per 1,000 inpatients; the study's authors estimate that on any given day, approximately 7,200 hospitalized patients are treated for CDI.2 Between 2002 and 2004, Louis Stokes Cleveland Veterans Affairs (VA) Medical Center experienced a significant increase in CDIs, with incidence rates reaching roughly 15 cases per 10,000 patient days.3
- Leading to health risks, high costs: Symptoms include watery diarrhea (often lasting for days), fever, loss of appetite, nausea, and abdominal pain. Severe cases can lead to colitis, perforations of the colon, sepsis, and, in some cases, death.4 Estimated mortality is 4.2 percent, and in 2007, the costs of treating each case were estimated at $4,475.5
- Difficult to contain: In hospitals, CDI most commonly begins as an unintended consequence of treatment with antibiotics for other infections. Once present, the infection spreads relatively easily from patient to patient, with many cases resulting from hospital staff spreading bacteria from their hands onto medical equipment or directly to patients. Reducing patient-to-patient transmission requires diligence because spores from the bacterium can survive for months on surfaces such as floors, bed rails, furniture, sinks, bedpans, telephones, toilet seats, and stethoscopes, and alcohol-based hand gels do not inactivate the spores.5
- Suboptimal environmental cleaning: Environmental cleaning processes in many health care facilities remain suboptimal.6,7 For example, in 2009, Louis Stokes Cleveland VA Medical Center found that cultures collected from the rooms of patients with CDIs were often positive even after the rooms had been cleaned by environmental services personnel.3
- Promising but untested strategies: Several promising strategies may improve cleaning processes, including monitoring and feedback to environmental services personnel and use of various automated disinfection devices, such as ultraviolet (UV) radiation devices, that can reduce dependence on staff to apply disinfectants thoroughly. However, they remain largely untested in real-world settings.7
Description of the Innovative ActivityThe Louis Stokes Cleveland VA Medical Center tested a multicomponent strategy to improve room cleaning processes, with the goal of reducing the spread of CDIs. Launched sequentially over time, the components included: monitoring and feedback to environmental services personnel on the thoroughness of cleaning and disinfecting (aided by use of a fluorescent marker), UV disinfection devices for terminal cleanings of rooms of patients with CDIs, a dedicated team of housekeepers to provide daily cleanings of rooms of patients with CDIs, and supervisors to monitor terminal cleanings and “clear” rooms for the next patient. Each component is described in more detail below:
- Monitoring and feedback, with use of marker: Environmental services supervisors or infection control staff provided monitoring and feedback to department staff on the thoroughness of their cleaning and disinfecting efforts, aided by use of a fluorescent marker applied before the cleaning to 14 frequently touched surfaces (e.g., bed rails, bedside tables, telephones). For the first 8 months, monitoring and feedback covered cleanings of all hospital rooms after patient discharge; after this time, the feedback expanded to include a review of daily cleanings, but only for the rooms of patients with CDIs. Although this component has now been scaled back (as other program components were introduced and proven effective), the initial monitoring and feedback process worked as outlined below:
- Monthly department and other small-group meetings: During monthly department meetings and small-group sessions with housekeeping teams on individual wards, the program leader reviewed general information on CDIs, recommended proper cleaning and disinfection processes, and shared baseline and current performance data for the department as a whole on the proportion of high-touch surfaces being cleaned properly with bleach. As part of this process, the leader highlighted progress made since the last meeting, and noted particular surfaces where the thoroughness of cleaning needed improvement (such as the under-surface of bed rails).
- One-on-one education: As part of their regular rounds to assess the thoroughness of cleaning, environmental services supervisors directly observed and commented on the cleaning process employed by housekeeping staff. This observation generally occurred when the supervisors’ rounds coincided with the room cleanings; on average, this approach resulted in each member of the housekeeping staff being directly observed roughly once a month. During these one-on-one sessions, the supervisor offered suggestions to improve the cleaning process. For example, often housekeeping staff did not leave the bleach on the surface long enough before wiping it off, which can lead to residual pathogen remaining on the surface.
- UV cleaning device added to standard regimen for terminal cleanings: After 14 months, the program expanded to include use of a portable UV disinfection device as an adjunct to the standard terminal cleaning and disinfecting process for rooms with patients with CDI. During the first month, the device was employed on two medical wards, after which use expanded throughout the facility. After completing the at-discharge cleaning, environmental services staff wheel the portable device into the room, plug it in, and activate it using a hand-held remote control after leaving the room. The device runs for roughly 45 minutes (if anyone enters, it automatically shuts off), after which staff return and run an additional 10-minute cycle in the bathroom. At the 215-bed facility, roughly 4 to 10 rooms each week require such cleanings.
- Dedicated team for daily cleanings of CDI rooms: Four months after introduction of the UV cleaning device, the program expanded further to incorporate use of a three-person team of housekeepers dedicated to daily cleaning of rooms with CDI patients. The team is made up of three experienced, highly motivated staff who volunteered for this role. Each day the team receives a list of rooms (typically four to six) with CDI patients and takes charge of cleaning them as an adjunct to their regular duties. Using a dedicated team helps to remove variability in the quality of cleaning and hence reduces the need for intense monitoring of all housekeeping staff.
- At-discharge “clearing” of CDI rooms for next patient: Concurrent with the introduction of the dedicated team, environmental services supervisors and infection control staff began monitoring the terminal cleaning and disinfection process for CDI rooms, which is still performed by regular housekeeping staff. This monitoring reminds housekeepers that CDI rooms require special attention and allows for quick feedback to address problem areas. The process works as outlined below:
- Monitoring during or after cleaning process: In many cases, someone observes housekeeping staff as the cleaning takes place, providing immediate feedback on missed steps or suboptimal techniques (e.g., not leaving the bleach on high-touch surfaces long enough to kill the bacteria). In other cases, monitoring occurs shortly after the room has been cleaned.
- Aided by analysis of high-touch surfaces: Along with visual assessments, observers take adenosine triphosphate (ATP) readings of high-touch surfaces. These readings measure the amount of organic material remaining on the surface, with low readings correlating to effective cleanings. Whenever an ATP reading is 250 relative light units or higher for one or more surfaces, the housekeeping team cleans and disinfects the surface(s) again, either right away (if the housekeeping staff are still in the room) or after the observer notifies the department of the high readings and the need for additional cleaning.
- Clearing room for next patient: Once the high readings have been eliminated and the room has been cleaned to the observer’s satisfaction, he or she “clears” it for the next patient.
Context of the InnovationPart of the VA Healthcare System of Ohio, the Louis Stokes Cleveland VA Medical Center provides a full range of primary, secondary, and tertiary care services to eligible veterans in 24 counties in Northeast Ohio. The center serves more than 105,000 veterans each year through a 215-bed hospital, 165-bed long-term care facility, 13 multispecialty clinics, veterans’ centers, and community-based facilities and nursing homes under contract with the medical center. In 2012, the medical center handled more than 11,000 admissions and more than 1.8 million outpatient encounters.
The impetus for this program dates back to the early and mid-2000s when, like many other hospitals throughout the country, the medical center experienced a significant outbreak of CDIs related to a new strain of the infection. In response, leaders initiated a variety of practices to improve environmental cleanings and stem the outbreak. Though these efforts achieved a fair amount of success, it became clear over time that a more structured and consistent monitoring process was needed to effectively control the spread of CDIs. In fact, in 2009, tests indicated that rooms that had been cleaned by environmental services personnel often tested positive for the Clostridium difficile pathogen. (As a research facility, the medical center could collect and analyze cultures; many community hospitals cannot easily take this step.) Around the same time, new methods and techniques—including the fluorescent marker—were being developed to improve cleaning and disinfecting processes. Consequently, infection control and environmental services leaders within the medical center decided to begin testing additional strategies to reduce the spread of CDIs, including use of some of these new techniques.
ResultsThe education and feedback component meaningfully improved the thoroughness of cleaning, and the overall program significantly reduced the proportion of rooms of CDI patients with positive cultures and the overall incidence of healthcare-associated CDIs, with the bulk of the improvement occurring after introduction of the dedicated team and “clearing” process at discharge.
Moderate: The evidence consists primarily of pre- and post-implementation comparisons of CDI rates and key metrics related to the quality of the cleaning and disinfecting process in the rooms of patients with CDIs, including the proportion of high-touch surfaces cleaned and the percentage of such rooms containing positive cultures.
- More thorough cleaning: The education and feedback significantly increased the thoroughness of cleaning, as the proportion of high-touch surfaces that were cleaned increased from 47 percent to 81 percent after introduction of this component.3
- Large decline in positive cultures, particularly after introduction of dedicated team: The education and feedback yielded a modest 14-percent decline in the prevalence of CDI rooms with positive cultures (from 67 percent to 57 percent), as compared to before the intervention. Introduction of the UV device yielded further benefits, with the proportion of rooms with positive cultures falling to 35 percent. (However, fluorescent marker readings and visual observation suggest the quality of standard terminal cleaning suffered, as staff began to rely on the UV device and became less thorough in their efforts.) Once the dedicated team and room-clearing process was added, significant additional declines occurred quite quickly, with the percentage of rooms testing positive falling from 35 to 7 percent, 89 percent below baseline levels.3
- Decline in overall CDI rates: Overall incidence of health care–associated CDIs fell by 30 percent in the year after introduction of the dedicated team and the CDI room-clearing process, as compared to the rate in the year before their introduction.
- Positive feedback from staff, few patient complaints: Housekeepers have not expressed any concerns about the program (including the at-discharge clearing process), and have responded quite favorably to receiving feedback on their performance. In addition, the CDI team reported that the vast majority of patients accepted the daily disinfection with bleach wipes without complaint.3
Planning and Development ProcessKey steps included the following:
- Sharing baseline performance with administrative, department leaders: To secure buy-in from key constituencies, the program leader shared baseline performance information with hospital administration, the infection control committee, and leaders of the environmental services department. These data illustrated the magnitude of the opportunity for improvement. Program leaders also discussed new techniques available to reduce the spread of CDIs, including fluorescent markers and UV cleaning devices.
- Developing monitoring and feedback component: The program leader worked with the multidisciplinary infection control committee, which includes representatives from environmental services, to develop and implement the monitoring and feedback component, including how the fluorescent markers would be used.
- Introducing approach to environmental services staff: The program leader attended regular meetings of environmental services staff to provide an overview of CDIs (including why they are a concern for patients) and review the proposed approach to preventing their spread. During these sessions, he emphasized the nonpunitive nature of the program, ensuring them it would in no way affect future performance reviews. Rather, he positioned it as a way to improve patient care without creating an undue additional burden on staff.
- Evaluating and refining the approach over time: As described earlier, the initial single-pronged approach expanded over time after initial results suggested additional room for improvement in eliminating the CD pathogen. When the UV device was introduced, housekeeping staff attended brief training sessions to learn to use it. At present, the hospital continues to use all three components, although the monitoring and feedback component has been scaled back significantly since introduction of the dedicated team.
Resources Used and Skills Needed
- Staffing: The medical center did not hire additional staff for this program, as existing personnel incorporate program-related activities into their regular job responsibilities. The initial monitoring and feedback component proved to be quite labor intensive, as it took significant time for infection control staff to administer the fluorescent markers before cleanings, check them afterwards, and provide one-on-one feedback to environmental services staff. In addition, environmental service department leaders initially spent significant time attending group meetings, although this commitment has declined as the hospital scaled back this part of the program. When used (roughly 4 to 10 times a week), the UV device adds approximately 15 minutes to the terminal cleaning process for a room, because staff must retrieve the device (sometimes from another floor) and run it separately in the main room and bathroom. Finally, the process of clearing CDI rooms requires roughly 1 to 2 hours per week for environmental services supervisors or infection control personnel.
- Costs: The hospital uses two portable UV devices; the cost of such devices varies significantly depending on the model and features chosen, with prices ranging from $20,000 to $120,000. Other program-related costs are minimal.
Funding SourcesAgency for Healthcare Research and Quality; Department of Veterans Affairs
The VA provided a grant to support the medical center’s activities related to environmental disinfection, including work on this program. The Agency for Healthcare Research and Quality (AHRQ) provided a grant (R18 HS20004-01A1) to support program evaluation. The medical center is currently using a separate AHRQ grant to work with other hospitals in the Cleveland area to reduce the spread of CDIs.
Getting Started with This Innovation
- Assess and share data on performance: The baseline data help to determine what, if any, issues exist with respect to cleaning and disinfecting rooms, including whether the pathogen remains after cleaning of CDI rooms and whether it has spread to the rooms of other patients who do not have the infection. This information can be used to determine the need for a program and where to focus any efforts. Community hospitals that lack the ability to collect and analyze cultures may be able to contract with an outside laboratory to perform this task, or can use fluorescent markers to assess the thoroughness of cleaning as a proxy for culturing. Technological advances may allow more organizations to culture or detect CDI at a reasonable cost in the future.
- Include environmental services staff on implementation team: This step helps to ensure buy-in from housekeeping staff and creates a mechanism for getting their valuable input on how best to structure and implement the program.
- Carefully consider need for UV device: Although Louis Stokes Cleveland VA Medical Center continues to use the UV devices they already purchased, would-be adopters should consider whether purchasing them is necessary. As noted earlier, program evaluation found that the devices modestly improved the ability to eliminate the Clostridium difficile pathogen, but also resulted in some decline in the thoroughness of cleanings at discharge.
- Create dedicated team for daily cleanings: As noted, creating a small team of experienced, motivated environmental services staff dedicated to the daily cleaning of the rooms of CDI patients yielded immediate and significant improvements, and hence represented the single most important component of the program. This strategy not only reduces variability in and maximizes the effectiveness of daily cleaning, but also diminishes the need for labor-intensive monitoring and feedback of the entire housekeeping staff.
Sustaining This Innovation
- Continue some level of monitoring and feedback: Even with the dedicated team, it still makes sense to provide periodic feedback to the entire housekeeping staff on the quality of their cleaning efforts. To that end, the program leader periodically attends department meetings to share performance information and elicit input from staff.
- Publicize and celebrate successes: At Louis Stokes Cleveland VA Medical Center, the hospital director regularly acknowledges the great progress that the environmental services department has made. In addition, television screens posted throughout the hospital periodically highlight the accomplishments of this program, incorporating pictures of staff along with charts and other information documenting the improvements.
Contact the InnovatorCurtis J. Donskey, MD
Geriatric Research Education and Clinical Center
Louis Stokes Cleveland VA Medical Center
10701 East Boulevard
Cleveland, OH 44106
Tel: (216) 791-3800, ext. 6153
Innovator DisclosuresIn addition to the funders listed in the Funding Sources section, Dr. Donskey reported receiving grants/contracts from Pfizer, Cubist, ViroPharma, and Merck; he is also a board member for 3M and consults for EcoLab.
References/Related ArticlesSitzlar B, Deshpande A, Fertelli D, et al. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 2013;34(5):459-65. [PubMed]
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Jarvis W, Schlosser J, Jarvis A, et al. National point prevalence of Clostridium difficile
in US health care facility inpatients, 2008. Am J Infect Control. 2008;37(4):263-70. [PubMed]
Sitzlar B, Deshpande A, Fertelli D, et al. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile
isolation rooms. Infect Control Hosp Epidemiol. 2013;34(5):459-65. [PubMed]
Whitaker J, Brown BS, Vidal S, et al. Designing a protocol that eliminates Clostridium difficile:
a collaborative venture. Am J Infect Control. 2007;35(5):310-4. [PubMed]
Eckstein BC, Adams DA, Eckstein EC, et al. Reduction of Clostridium difficile
and Vancomycin-resistant Enterococcus
contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007;7:61. [PubMed]
Carling PC, Parry MM, Rupp ME, et al; Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:1035-41. [PubMed]
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Original publication: January 15, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.