TASMANIAN INFECTION PREVENTION AND CONTROL UNIT

Evaluating environmental cleanliness in

hospitals and other healthcare settings
What are the most effective and efficient
methods to use?

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Evaluating environmental cleanliness in hospitals and other healthcare settings
What are the most effective and efficient methods to use?
Tasmanian Infection Prevention and Control Unit (TIPCU)
Department of Health and Human Services, Tasmania

Published 2012
CopyrightDepartment of Health and Human Services

Permission to copy is granted provided the source is acknowledged

ISBN 978-0-9872195-2-7

Contact: TIPCU
GPO Box 125
Hobart, Tasmania, Australia, 7001
Email: [email protected]
Website: www.dhhs.tas.gov.au/tipcu

Author affiliations:
Brett Mitchell, Tasmanian Infection Prevention and Control Unit, Department of Health and
Human Services, Tasmania and Australian Catholic University, School of Nursing Midwifery and
Paramedicine.
Fiona Wilson, Tasmanian Infection Prevention and Control Unit, Department of Health and
Human Services, Tasmania.
Chris Ware, formerly of Tasmanian Infection Prevention and Control Unit, Department of
Health and Human Services, Tasmania.
Saffron Brown, formerly of Tasmanian Infection Prevention and Control Unit, Department of
Health and Human Services, Tasmania.
Dr Alistair McGregor, Tasmanian Infection Prevention and Control Unit, Department of Health
and Human Services, Tasmania.
Dr Stephanie Dancer, Consultant Microbiologist, National Health Service, Lanarkshire, Scotland,
UK.
Editors:

Brett Mitchell, TIPCU

Fiona Wilson, TIPCU
Dr Alistair McGregor, TIPCU
Dr Stephanie Dancer, Consultant Microbiologist, National Health Service, Lanarkshire, Scotland,
UK.

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Page 2 of 31
Contents
Contents ............................................................................................................. 3
Foreword ............................................................................................................ 4
1. Overview ........................................................................................................ 5
2. The Importance of the Environment and HAI Prevention ...................... 6
2.1 Summary ...................................................................................................................................................... 8

3. Why Evaluate Environmental Cleanliness? ................................................ 9

4. Methods of Assessment .............................................................................. 10
4.1 Monitoring the cleaning process.......................................................................................................... 10

4.2 Measuring the outcome of cleaning .................................................................................................... 12

5. Summary of Audit Methodologies ............................................................ 15

6. Local, National and International Practices............................................. 16
6.1 Tasmanian practices................................................................................................................................ 16

6.2 Australian jurisdictional practices........................................................................................................ 17

6.3 Summary .................................................................................................................................................... 19

7. Local and International Guidelines ........................................................... 20

8. Acknowledgements..................................................................................... 21
References ........................................................................................................ 22
Appendix 1: Suggested Standards for Microbial Sampling of the
Healthcare Environment ................................................................................ 27
Appendix 2: Interview Questions .................................................................. 28
Appendix 3: Interstate Cleaning Assessment Methodology ...................... 30

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Foreword
We believe that the environment plays an important part in infection prevention and control. For
this reason, we consider the evaluation of environmental cleanliness to be an integral part of any
infection prevention and control program.

Numerous studies in the literature discuss novel methodologies that assess both the extent of
environmental contamination in the hospital environment and efficacy of cleaning. Methods of
assessing environmental cleanliness can be broken down into two types: process evaluation, such as
visual inspection and fluorescent gel application, and outcome evaluation, where cleanliness is
measured using methods such as adenosine triphosphate (ATP) or microbial cultures. An important
fact to remember, however, is that just because the environment may appear dirty, this does not
necessarily mean it poses an increased risk of infection for patients. Conversely, an environment
that appears clean may harbour microorganisms that are potentially harmful.

The purpose of this review is to describe some of the main methodologies currently used in
assessing environmental cleanliness as well as document current local, national and international
practices. Following the completion of this report, we aim to bring together relevant and interested
parties from across Tasmania to present the findings, identify options for potential future use within
Tasmania, and have an open discussion around other issues regarding environmental cleaning and
infection control within healthcare environments.

Our ultimate goal would be to see a standardised approach to evaluating environmental cleanliness
within Tasmanian healthcare facilities. Although we are at the beginning of this journey, this report
is the first step towards achieving this.

Brett Mitchell Dr Alistair McGregor

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1. Overview
Authors: Brett Mitchell, Chris Ware

Healthcare associated infections (HAIs) have a major impact on our healthcare service and the
population it serves. Large prevalence studies from several countries indicate that approximately 8
per cent of hospitalised patients will acquire an infection as a result of receiving healthcare (1, 2).
Within Australia there are an estimated 200,000 cases of HAI occurring each year, which equates to
around 2,300 cases within Tasmania (3).

HAIs affect the morbidity and mortality of patients and also result in adverse events such as
prolonged length of stay in hospital. In addition to hospitals, HAIs affect patients in other healthcare
settings such as long-term care facilities and general practice.

No single cause of, or quick fix for, the problem of HAIs exists at present. Evidence suggests that
the issue needs to be tackled using a multi-faceted approach. Understanding the modes of
transmission of infectious agents and applying basic principles to prevent infection are critical to
reducing the occurrence of HAIs. Some fundamental requirements for preventing infection in
healthcare environments are cleanliness of hands and the environment, the isolation of patients
known or suspected of having easily transmissible or epidemiologically important pathogens,
targeted screening and antimicrobial stewardship.

One key element in infection prevention is environmental cleaning. In December 2010, the
Tasmanian Healthcare Associated Infection Advisory Group supported TIPCU to undertake a
review of environmental hygiene practices in healthcare facilities. The objective of the present
review is to assess current local, national and international practices and literature in relation to
evaluation of environmental hygiene in healthcare environments.

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2.The Importance of the Environment and HAI
Prevention
Authors: Brett Mitchell, Dr Alistair McGregor, Chris Ware

A wide range of microorganisms can cause infections in a healthcare setting. To understand how the
environment may play a part in the occurrence of infections, it is important to think beyond the
endpointthe infected patient. For example, persons colonised with microorganisms can
contaminate the environment. In turn, these microorganisms can be transferred to other sites, most
commonly by the hands of healthcare workers, patients and visitors. Microorganisms acquired from
these sites may then be responsible for infection in other patients. In the past, the role of the
inanimate hospital environment (e.g., surfaces and equipment) in the spread of HAIs has been
regarded as controversial (4). However, a large body of evidence now supports the notion that the
environment does play a part in microorganism transmission and subsequent infection.

The potential for contamination of environmental surfaces to contribute to transmission of

healthcare associated pathogens depends on a number of factors, including the:
ability of pathogens to remain viable on a variety of environmental surfaces
frequency with which organisms contaminate surfaces
location of reservoirs
handling frequency of surfaces and whether or not levels of contamination are sufficiently high
to result in transmission to patients (5).

The time that pathogens remain viable in the environment varies considerably and depends upon
the particular characteristics of the organism. Research conducted by Colbeck (6) demonstrated
that Staphylococcus aureus, the organism responsible for most HAIs in Australia, can remain virulent
and capable of causing infection for at least 10 days after inoculation onto a dry surface.

The idea that microorganisms can survive for long periods in the environment has been supported
by numerous studies (7, 8). Unless adequate cleaning is undertaken, microorganisms in the
healthcare environment may contaminate hands or uplifting air currents and be subsequently
deposited onto a patient or surfaces near a patient (9-13). Sites considered to be hand-touch sites
are of particular importance. Microorganisms do not discriminate between environmental sites and
when they persist on sites that are likely to be touched regularly, there is a risk of onward
transmission to patients via healthcare workers hands.

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Figure 1: Transmission cycle demonstrating the role of the environment

Several studies have shown that persistence of microorganisms in the environment leads to an
increased risk of acquiring an infection in a patient who is admitted to a room previously occupied
by a patient colonised or infected with that particular organism (14, 15). Environmental
contamination in conjunction with colonisation pressure (i.e., the proportion of patients colonised
with an organism) is thought to play a role in transmission of microorganisms. This concept has
been demonstrated to explain the transmission of organisms such as methicillin-resistant
Staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE) in the healthcare
environment (16-19).

For Clostridium difficile, which is transmitted in a similar fashion to VRE, colonisation pressure or the
proportion of other patients colonised with the same organism, and the environment are also
thought to play important roles in transmission. This has been shown to be the case in a
retrospective cohort and nested case control study of 36,000 admissions. Following multivariate
logistic regression, the authors suggest that the more patients there are with Clostridium difficile
infection on a hospital ward, the more likely it is that other patients will acquire the organism (20).
Environmental contamination with spores is now well accepted as a risk factor for the acquisition of
Clostridium difficile.

Microorganisms can be found on a large number of surfaces in the healthcare environment (21).
Items in close proximity to the patient tend to be more heavily contaminated than those that are
more remote. The greatest risk of acquiring microorganisms that result in infection has been
suggested to arise from near-patient items such as bed rails and bedside tables, as contamination of
these sites provides frequent opportunity for hands to touch and transfer organisms. Paradoxically,
however, the thoroughness of cleaning appears sometimes to be oriented towards those sites that

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are traditionally or aesthetically important, or physically easier to clean, rather than sites that have
the most significant potential for harbouring and transmitting microbes (22).

Figure 2: Frequently touched objects in the patient environment

Published studies demonstrating the importance of cleaning in outbreak scenarios underscore the
likely role that environmental contamination plays in the transmission of HAIs (23). Multiple studies
have shown that enhanced cleaning significantly decreases environmental contamination by a range
of HAI pathogens (21, 24-27). These studies, alongside the known role of colonisation pressure,
demonstrate the potentially important role that the environment plays in infection transmission and
prevention.

2.1 Summary

The healthcare environment plays a role in transmission of microorganisms that may cause
infection and therefore potentially has a role in prevention.
Near-patient (frequently touched) objects are often contaminated with potentially pathogenic
microorganisms and therefore pose the greatest risk for the transfer of pathogens.
The risk of acquiring a specific organism is increased if a patient is admitted to a room
previously occupied by a patient who had been colonised or infected with that organism.
Environmental cleaning reduces environmental contamination thus can reduce the risk of
transmission of infection.

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3. Why Evaluate Environmental Cleanliness?
Authors: Brett Mitchell, Dr Alistair McGregor

A considerable international debate currently exists regarding the role of the environment in HAIs
and the best way or ways to evaluate environmental cleanliness. The public has linked the visual
appearance of a hospital with the risk of HAI but there is currently little evidence to support this
view (28). The role of environmental cleaning has been acknowledged and promoted in published
guidelines, with many government-sponsored documents prescribing some form of quality assurance
audit or assessment. However gaps remain between what is outlined as best practice in these
documents and what is actually occurring. In part, this is due to a lack of generally accepted
scientific standards, which further confounds the ability to demonstrate an undisputed role for the
environment in HAIs (29-32).

A number of reasons can be listed to show why evaluating environmental cleanliness (a form of
surveillance) in a standardised format is warranted. These include:

the need to evaluate the effectiveness of interventions

to detect trends
to provide a framework for performance management
to provide reliable data to support quality improvement activities
to ensure that staff in hospitals have relevant and useful information to inform their practice.

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4. Methods of Assessment
Authors: Chris Ware, Fiona Wilson, Saffron Brown

Studies are appearing in the literature describing novel methods for assessing both the efficacy of
cleaning and the extent of environmental contamination in the hospital environment. Methods for
assessing environmental cleanliness can be broken down into two types: process evaluation, where
the cleaning process is monitored by visual inspection or using a fluorescent gel marker; or
outcome evaluation, where cleanliness is evaluated with the use of ATP or microbial cultures (33).

This chapter will discuss these two methods for evaluating environmental cleanlinessmonitoring
the process and measuring the outcome.

4.1 Monitoring the cleaning process

4.1.1 Visual inspection

The primary method for assessing the cleanliness of healthcare environments is visual inspection
(33, 34). Visual inspection is generally undertaken by a healthcare professional, who carries out an
inspection of surface areas for visible dirt, soiling or moisture. Commonly, environmental cleanliness
audits are undertaken by environmental cleaning staff, and the effectiveness of these is intermittently
assessed by healthcare professionals such as infection control staff or trained monitoring consultants
(30, 31).

An increasing focus on methods for quantitative assessment of cleanliness in hospital environments

has highlighted many of the shortcomings of visual assessment. We identified six quantitative studies
that compared the performance of visual assessments with results from microbial swabbing or ATP
assays in the healthcare environment (25, 35-39). In all six investigations, visual assessment was
reported to perform poorly at identifying microbial load, typically passing between 1793 per cent
more surfaces as clean than other assessment methods. These studies reiterate that a visual
appraisal of cleanliness is not a proxy for decontamination.

While visual assessment of the cleanliness of a hospital ward, surface or item may satisfy aesthetic
obligations, it cannot reliably assess the infection risk posed to patients (34). It is the cheapest and
quickest of all methods described in this report however, requiring less training and fewer
personnel than other methods. As a means of providing a measure of the efficacy of hospital
cleaning and personnel performance, visual inspection has its merits: it is the only method that can
quickly assess all surfaces for gross deficiencies in a hospital ward that may harbour pathogens.

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4.1.2 Fluorescent gel
This method employs an invisible transparent gel that dries on surfaces following application and
resists dry abrasion, but is easily removed with light abrasion after wetting. The gel is visible only
under a UV lamp so the thoroughness of cleaning can be determined following cleaning by using a
UV lamp to illuminate surfaces where the gel was applied. We identified five studies that have tested
the thoroughness of routine hospital cleaning and the effect of cleaning interventions and that were
able to demonstrate the thoroughness of cleaning administered by cleaning personnel using this
method (22, 29, 40-43).

The fluorescent gel method readily demonstrates a lack of attention to those surfaces in the near-
patient zone that routinely harbour high concentrations of bacteria and pathogens. Targeting objects
and their subsequent evaluation following cleaning has been shown to take less than two minutes
per room for each activity (40), permitting cleaning evaluation to be undertaken on a large scale.
Furthermore a fluorescent gel application can provide a more standardised approach to process
evaluation compared to visual inspection.

Figure 2: Examples of a fluorescent marker

Note: Pictures of the DAZO Fluorescent Marking Gel and UV Light pen are used with permission from Ecolab

As with visual assessment of environmental cleanliness, which evaluates cleaning performance rather
than environmental contamination per se, this method relies upon the assumption that improved
cleaning procedures can reduce environmental sources of pathogens (44) and have a favourable
impact on transmission (24). Addressing cleaning performance therefore remains a vital step in the
initial evaluation of environmental cleaning and the use of a fluorescent marking system to monitor
cleaning provides an effective method to accomplish this.

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4.2 Measuring the outcome of cleaning

4.2.1 ATP bioluminescence

The measurement of ATP is the first of two methods commonly employed for specific sampling of
the bioburden in the hospital environment. ATP is the basic energy component molecule of all plant
and animal cells and is in all microorganisms and organic residues. Sampling a surface for ATP
measures the amount of organic soil, including microorganisms, on that surface. The method uses a
specialised swab to sample a standardised area. The swabs are placed in a detection device that uses
the firefly enzyme and substrate luciferase and luciferan, respectively, to catalyse a reaction with
ATP. Light output from the reaction is proportional to the amount of ATP present, and can be
measured with a luminometer (measured in relative light units, or RLUs). While considerable
variation can occur in the readouts (14, 45, 46) and in the sensitivity (47) of commercially available
systems, very low readings are typically associated with low aerobic colony counts (ACC) on
surfaces(48).

Figure 3: Example of an ATP bioluminescence system

Note: Pictures of the 3M Clean-TraceTM system are used with permission from FOSS

ATP measurement has been used to evaluate cleanliness of food preparation surfaces for over 30
years (33, 35). The measurement of ATP is increasingly being used in a number of studies of hospital
surface contamination where ATP is typically measured in addition to microbial swabbing, either to
evaluate cleaning performance or to test the success of a cleaning intervention (25-27, 35, 36, 38,
39, 48, 49).

The benefits of using ATP measurements to evaluate hospital cleanliness are, broadly, three-fold:
1. Results of residual surface ATP can be delivered within 20 seconds of sampling (38).
2. The ease of use of ATP measurement systems and the substantially reduced level of training
required to use the system provides an additional suite of benefits, including compelling
educational strategies (39).
3. Benchmarking is a benefit of using ATP to evaluate cleanliness.

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Efforts to establish a basis from which to assess surface hygiene have resulted in proposals for ATP
standards (34-36, 49). However, difficulties emerge when benchmarking differing ATP systems, as
ATP results with one system may not necessarily be comparable to those generated by a different
system. These differences could be corrected by producing a calibration curve for a variety of
known clean and dirty surfaces prior to sampling (39).

Limitations of the use of ATP measurement systems are found in both the propensity of systems to
produce false positives, and in the ability of the system to produce accurate results on all surfaces.
ATP measurements provide a quantification of all organic material collected from a swab, including
viable bacteria, but also including non-viable bacteria and non-microbial organic debris such as food
and liquids such as milk, blood or urine (36). Thus, any ATP result may represent the ratio of these
or other ATP-producing organisms. However, means are available for distinguishing the ratio of
microbial to non-microbial components of an ATP measurement by enzymatic removal of non-
bacterial ATP before the assay. Studies that have done this calculated that 33 per cent of the ATP
load was attributable to microbial organisms (35, 50).

Nevertheless, the viability and identification of microbes (typically bacteria) in these examples still
remains unknown. For this reason, ATP measurements have a low sensitivity and specificity in
detecting bacteria, with one example finding that using an ATP measurement system had a
sensitivity and specificity of just 57 per cent (49), which could be considered to be too great a
margin of error to justify stringent monitoring using this method alone. The capacity for ATP
measurement systems to produce accurate results can also be compromised by factors such as
residual detergents or disinfectants including sodium hypochlorite, (51, 52), surfaces in poor
condition (35), plasticisers found in microfibre cloths or ammonium compounds found in laundry
products (53). These factors may all either increase or decrease ATP readings (33).

4.2.2 Microbial methods

Microbial methods for evaluating environmental cleaning have long been used to evaluate surface
contamination and have been the principal methods employed in hospitals to assess surface
cleanliness (54). Through the late 1950s and 1960s, microbiological culturing was common practice
as part of ongoing hospital monitoring programs (33) and accordingly, colony counts, Rodac plate
counts, and quantitative air sampling were all routinely performed on the hospital environment and
even inanimate objects (54). In hospitals today, microbial evaluation typically targets a range of
surfaces within wards, equipment, or work stations and involves the use of swabs or dipslides to
culture organisms in order to gain a standardised ACC and/or to detect the presence of specific
bacteria. This type of investigation is generally only recommended as part of an outbreak
investigation, as a component of research, or as part of policy or process evaluation (31, 55).

Microbiological evaluation of hospital surfaces provides the most accurate indication of infection risk
of all the methods discussed because it can detect and identify viable bacteria and fungi. Reasons for
not advocating microbiological evaluations in all situations centre on the time and resources
required to process conventional microbiological cultures. The time taken to enumerate ACCs or

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identify pathogens may be at least two days, and specific expertise as well as microbiology
laboratory access are required. In 2004, Dancer proposed two microbiological standards for
assessing environmental hygiene; namely, the presence of an indicator organism or the breaching of
a quantitative ACC. The details of these methods are summarised in Appendix 1.

While microbiological methods can produce results with high specificity, sampling techniques have
varied sensitivity and often under-sample a surface, thereby hindering accurate assessments of
surface contamination and study comparability. Briefly, swabs, dipslides, sampling sponges, and settle
plates may all be used to sample surfaces, and the choice of sampling method will affect the final
ACC measurements. Dipslides have been evaluated as having superior sensitivity and consistency,
particularly for dry surfaces, while swabs will not always pick up bacteria present on surfaces, and
can retain bacteria within the swab bud itself (56-58). Finally, an airborne component of infection
risk may also exist in a ward and can often be overlooked in studies. Settle plates and air samplers
have been used to measure airborne contamination caused by floor mopping (45) and bed making
(59), as well as routine cleaning (60).

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5. Summary of Audit Methodologies
Authors: Chris Ware, Fiona Wilson, Saffron Brown

A review of the literature demonstrates that benefits and limitations exist for all methods of
environmental cleaning evaluation. These are summarised in Table 1. Methods that evaluate cleaning
performance are useful in assessing adherence to cleaning protocols, whereas methods that sample
bioburden provide a more relevant indication of infection risk. Risk is more accurately related to
hand touch frequency and level of surface contamination with specific pathogens, in combination
with routes of transmission (36). Fast, reproducible, and reliable methods are needed for
environmental cleaning evaluation in order to predict timely clinical risk.

Table 1: Summary of methodologies

Advantages Disadvantages
Assessing Performance
Visual Can be used for large areas (wards, Subjective
inspection rooms) Does not assess bioburden
Can be done with minimal training Does not correlate with bioburden
Benchmarking possible Can be confounded by clutter, fabric deficits and odours
Simple and inexpensive
Fluorescent gel Quick Does not assess bioburden
Provides immediate feedback on Could be labour intensive as surfaces must be marked
performance before cleaning and checked post cleaning
Minimal training required
Objective
Benchmarking possible
Relatively inexpensive
Assessing Outcome
ATP Quick Expensive
bioluminescence Provides immediate feedback Low sensitivity and specificity
Minimal training required No current standardisation of tests
Objective Variable benchmarks
Technology constantly changing
Microbial High sensitivity and specificity Expensive
cultures Objective Prolonged time for results
Provides direct indication of the Requires accessible laboratory resources and trained
presence of whatever pathogen is personnel for interpreting results
isolated Not supported for routine use by local and international
May suggest environmental guidelines
reservoir(s) and/or source of Few laboratories NATA accredited to perform these
outbreak tests
Requires standardised benchmark to assess infection
risk
Note: Disadvantages of all of these methods includes requiring feedback to cleaners, the fact that
they may lose impact over time and that they need to be linked with formal performance indicators.

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6. Local, National and International Practices
Authors: Fiona Wilson, Saffron Brown, Chris Ware

As part of the review of environmental hygiene practices in healthcare facilities, the TIPCU engaged
with local and national stakeholders and posed a number of questions regarding assessment of
environmental cleanliness within their healthcare facilities. Both national and international guidelines
were reviewed in regard to recommendations made about assessing environmental cleanliness.

6.1 Tasmanian practices

6.1.1 Methods
Each of the Area Health Services were contacted by TIPCU, which requested help in identifying the
key stakeholders in their acute hospitals, such as the heads of environmental services and infection
control staff, and sought permission to discuss evaluation of environmental cleanliness with these
hospitals.

The TIPCU staff engaged with both environmental services staff and infection prevention and
control units at Royal Hobart Hospital, Launceston General Hospital, Mersey Community Hospital
and North West Regional Hospital. At these meetings, set questions were asked of the stakeholders
regarding their practices (see Appendix 2). Interviews were also held with Infection Control
representatives from the rural hospitals.

6.1.2 Findings
All of the larger acute hospitals surveyed use visual assessment as the primary method of assessing
environmental cleanliness. These audits are generally performed by the Environmental or Hotel
Services staff, with the exception of one hospital, where Infection Control staff undertake the
assessments.

Two hospitals audit both clinical and non-clinical areas, while the other two hospitals audit clinical
areas only. The frequency of auditing environmental cleanliness also varies between hospitals, with
one auditing all areas daily, one performing five audits per week, one doing two audits per week on
a rotating basis, and one doing audits depending on the results of the previous audit.

Only one hospital regularly uses any other methodologies for assessing cleanliness. This hospital
undertakes environmental swabbing as a measurement of the effectiveness of environmental hygiene
and disinfection following the discharge of patients with MRSA or VRE. This protocol is not used for
assessing routine cleaning of the hospital environment.

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The environmental cleaning assessments that occur within the four large acute public Tasmanian
hospitals are contained in a supplement to this report.

No routine, standardised cleaning assessments appear to occur within the rural hospitals.

6.2 Australian jurisdictional practices

6.2.1 Methods
Information regarding environmental cleaning assessments within healthcare facilities across
Australian jurisdictions was sought from the Infection Control departments within the State Health
Departments and/or via State and Territory Health Department websites. Questions included
whether cleaning was audited or assessed, the methodologies used, what training was undertaken,
frequency and sites of assessment, and whether there were documented cleaning protocols.

6.2.2 Findings
Canberra Hospital (Australian Capital Territory) uses an external cleaning company that uses the
Victorian Health audit tool (see below). The Victorian audit tool audits environmental cleanliness via
visual inspection. The cleaning company has its own policy and procedures but these were heavily
guided by the Canberra Hospital. Auditing is performed weekly in clinical areas and wards are
selected randomly. Risk assessment of all functional areas is carried out and the frequency of
auditing and acceptable quality level or score is based on this risk categorisation. Data are either
recorded electronically, directly onto a database, or manually via a paper-based system that is
entered onto the database at a later date.

Within Queensland public hospitals, cleaning is performed and assessed based on the Queensland
Health Cleaning Services, Policies, Standards and Operational Guidelines 2011 (personal
correspondence, F. Fullerton, Centre for Healthcare Related Infection Surveillance and Prevention
(CHRSP), June 2011, January 2012). Environmental cleanliness of both clinical and non-clinical areas
is assessed using a similar risk assessment framework to that used by Victoria and the ACT, where
environmental cleanliness is audited visually while the frequency of auditing and acceptable quality
level or score is based on an initial risk categorisation of functional areas. Queensland Health does
not recommend routine sampling of the environment as this is not deemed cost effective nor
supported by the literature. Environmental sampling is only recommended when conducting
research, during an outbreak investigation to identify an epidemiological link between environmental
sampling results and clinical isolates, or for quality assurance purposes.

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New South Wales does not have a statewide environmental cleaning assessment program in place,
but the HAI Environmental Hygiene Working Party is in the process of developing a future strategy
in regard to monitoring. The release of the new Environmental Cleaning Policy and the
accompanying Environmental Cleaning Standard Operating Procedures (ECSOP) is expected to
occur during 2012. The ECSOP are meant to provide step-by-step guidance for undertaking
environmental cleaning in healthcare and will replace the 1996 Cleaning Services Standards, Guides
and Policy for NSW Health Facilities which currently provides a framework for an effective and
efficient cleaning service that meets the needs of all users of hospital facilities. The Standards have
been framed to reflect the basic minimum policy standards, which must be adhered to, guidelines
based on a best practice methodology and a quality assurance program that will provide for an
ongoing monitoring process. This new policy will outline standards for environmental cleaning
within all NSW public healthcare facilities to ensure that facilities are clean and safe in order to
reduce the incidence of HAIs and will replace the section on environmental cleaning in the current
Infection Control Policy PD2007-036 (61). At present, PD2007-036 requires healthcare
organisations to have personnel responsible for the implementation, management and evaluation of
their cleaning service, as well as a means for evaluating the quality of their cleaning practice. While
there may not be a standard audit tool or methodology, cleaning services are monitored and
evaluated at a hospital level. Development of a standard audit tool for use in NSW public healthcare
facilities is expected to be a component of the implementation strategy for the new policy.

In the Northern Territory there is no state-wide cleaning assessment program in place. At the
Royal Darwin Hospital visual environmental assessments are performed biannually by Infection
Control personnel as part of the Infection Control Compliance Audits. No environmental swabbing
occurs as the microbiology laboratory does not process these swabs.

South Australia does not have a standardised state-wide cleaning and auditing program in place but
cleaning services are regularly monitored and evaluated at a hospital level. These evaluations occur
across a large number of SA public hospitals and a variety of assessment tools are used including
visual assessment, the White Glove Method and environmental swabbing. The frequency of use of
these methodologies varies, with visual assessment being the most common and frequent method of
assessment. The assessments are done predominantly via internal audits with some facilities also
having external assessments performed.

There is a current project that is developing cleaning standards for healthcare facilities across the
state and, once approved, the plan is then to move into the implementation phase. The proposal is
that hospitals will perform regular internal audits using a standardised tool that SA Health will
develop, plus have external audits done using an existing SA Health audit team. Auditors will be
suitably qualified to conduct cleaning audits against the standard.

Victoria has a comprehensive cleaning assessment program across all Victorian public hospitals
named the Cleaning Standards for Victorian Health Facilities 2011 (62). These standards, which
have been in place since 2000 with a major review in 2007, outline what the outcomes should be for

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cleaning within healthcare facilities and have been designed to simplify the visual assessment of
environmental cleaning. To summarise, surfaces, articles, items or fixtures that must be cleaned are
known as elements. There are 15 of these, grouped under four major headings. All areas and rooms
where cleaning is assessed are known as functional areas, and these are risk stratified into four risk
categories. These categories range from Avery high risk (areas such as Intensive Care Units), to
Bhigh risk (general wards), to Cmoderate risk (rehabilitation ward) and down to Dlow risk
(non-clinical areas). The acceptable quality level or score for each element and functional area is
based on the risk category. Auditing is a continuous process, and the number of rooms that are
visually assessed within a functional area is based on the risk category. For example, functional areas
A and B must have at least 50 per cent of rooms audited every month, while functional area C only
requires 50 per cent of the rooms audited at least quarterly. A pass or fail is reported for each
question related to each room element and all of the various elements within each functional area
are cross-referenced and weighted. Data are recorded on a hand held device, with direct entry
onto a database.

All hospitals must submit the results of two internal audits and one external audit to the Health
Department and this data is de-identified, benchmarked and published. Internal audits are performed
by trained hospital staff from various departments and the external audits are done by a qualified
Victorian Cleaning Standards Auditor. The results of the external audit contribute to Victorian
health services performance monitoring framework.

Western Australia does not have a state-wide program in place but within metropolitan hospitals,
cleaning services are monitored and evaluated at a hospital level. For example, the Royal Perth
Hospital audits environmental cleaning and they use the United Kingdom standards of visual
inspection for assessment.

The WA Country Health Service (WACHS), which covers all health services outside of the Perth
metropolitan region, has recently standardised their cleaning procedures, including the assessment
of environmental cleanliness. The auditing system and process is similar to the one used in Victoria
with risk assessments of all functional areas and the frequency of auditing and scores being based on
the risk category of the functional area. Cleanliness will be assessed visually and will be scored as
either Acceptable or Unacceptable. There are no specific definitions of these two terms.

6.3 Summary

The most commonly used method for assessing environmental cleaning within Australian
healthcare facilities is visual assessment. No jurisdictions routinely use any alternative
methodologies such as fluorescent markers, ATP bioluminescence or microbial counts for
assessing environmental cleanliness.
Even though all jurisdictions use visual assessment, the methods and programs used vary.

Page 19 of 31
7. Local and International Guidelines
Australian guidelines
Routine environmental sampling is not recommended as part of the National Health and Medical
Research Council guidelines owing to the limitations of the methods currently used worldwide.
Thus, cleaning audits are mainly carried out via visual assessment. A role for environmental sampling
may be considered in the management of a specific situation (31).

United Kingdom: National Health Service

The Patient Environment Action Team (PEAT) is a self-assessment framework developed in 2000
for use in all hospitals with more than 10 beds. This benchmarking tool enables hospitals to perform
an annual assessment of non-clinical services such as food, environmental cleanliness, hospital
access, signage, infection control and issues surrounding privacy and dignity. The cleanliness of both
the hospital environment and clinical and non-clinical equipment is visually assessed. The results of
the annual audit can then be benchmarked with the aim of improving non-clinical services. Each
year, a proportion of PEAT assessments are validated by an independent member (63).

United States of America: Centers for Disease Control

The Guidelines for Environmental Infection Control in Health-Care Facilities do not outline any
specific methodology for assessing environmental cleanliness, but they do recommend limiting
microbiological sampling for use in quality assurance purposes, epidemiological investigations or for
research purposes (55).

Page 20 of 31
8. Acknowledgements
The authors would like to acknowledge the following personnel for their input and assistance in this
report:

Tasmania
Executive Directors of Nursing.
Infection Prevention and Control Units.
Environmental and Hotel Services personnel.

Other jurisdictions
Australian Capital Territory
Fiona Kimber, Infection Control Department, Canberra Hospital.

New South Wales

Ronald Govers, Project Officer, Healthcare Associated Infections, Clinical Excellence Commission,
NSW Ministry of Health.

Northern Territory
Tain Gardiner, Infection Control Unit, Darwin Hospital.

South Australia
Irene Wilkinson, Infection Control Service Manager, SA Health.

Queensland
Fiona Fullerton, Nursing Director, Infection Prevention and Control, CHRISP, Queensland Health.

Western Australia
Rebecca McCann, Infection Control HISWA.
Mary-Rose Godsell, Nurse Consultant, Infection Prevention, WACHS.
Allison Peterson, Infection Control Nurse, HISWA, Healthcare Associated Infection Unit.

Page 21 of 31
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63 National Health Service. Patient Environment Action Team (PEAT). [cited 2012 Jan 4];
Available from: http://www.ic.nhs.uk/statistics-and-data-collections/facilities/patient-
environment-action-team-peat

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Appendix 1: Suggested Standards for Microbial
Sampling of the Healthcare Environment
The first standard was the presence of an indicator organism. These organisms included
Staphylococcus aureus (including MRSA), Clostridium difficile, VRE and various Gram-negative bacilli,
with the proposed standard being <1 cfm/cm2.

The second standard, ACC, was based on an internationally agreed figure used within the food
industry. The suggested standard was <5cfu/cm2 for hand contact surfaces.

Counts above the proposed standards could be used to assess the quality of the cleaning processes
used. Indicators of this type provide a level of accuracy where other methods of cleaning evaluation
cannot (34).

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Appendix 2: Interview Questions
1. Current practices in evaluating environmental cleanliness in Tasmanian
acute public hospitals

Do you work/liaise with environmental services around cleaning?

Who do you work/liaise with in environmental services?
Do you provide feedback to cleaning staff about their performance (if they are observed)?
Do you have a budget allocation for measuring environmental cleanliness in your facility?
Is evaluation of environmental cleanliness part of your annual quality plan?

2. Assessing the efficacy of cleaning

Do you undertake cleanliness audits to assess the performance of cleaning?

Do you use a definition of clean?
Do you use a checklist of surfaces?
Are visual audits undertaken?
Are internal visual audits conducted by a staff member who has appropriate knowledge/training?
Are external visual audits undertaken from a member of a trained organisation?
Do you use ATP Bioluminescence to sample bioburden in the environment?
Have you made any correlations between assessment scores and infection rates?

3. Assessing the microbial load of a surface

Do you use undertake environmental swabbing?

How often is environmental swabbing undertaken?
Do you/have you undertaken pre- and post-intervention assessment of cleaning?
Do you use swabs to sample surfaces?
Do you use dipslides to sample surfaces?
Do you use sampling sponges to sample surfaces?
Do you use settle plates to sample surfaces?
Please list the environmental sites/surfaces that you test.

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4. Monitoring cleaning personnel performance

Do you have written cleaning protocols?

Do your protocols specify how to clean?

Do your protocols specify who performs what tasks?
Do you check whether staff adhere to established cleaning protocols?
If yes, do you directly observe the staff cleaning practices? For example, are the specified sites
cleaned by the staff member and if yes, who actually does the monitoring?
Do you then mark surfaces as either cleaned or uncleaned?

5. What are the current environmental hygiene issues faced by your facility?
6. Would you like to see a standardised tool in Tasmania regarding assessment
of cleanliness?

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 Appendix 3: Interstate Cleaning Assessment Methodology
NSW ACT QLD NT WA SA VIC

Information Via telephone June 2011 and Via telephone June 2011 Via email June 2011 and Via telephone June 2011 and Via telephone and email Via email June 2011 and Via Health Department
source via email January 2012 January 2012 via email January 2012 January 2012 February 2012 Victoria website June 2011 and
email January 2012

Is cleaning No current state-wide Yeshave external cleaning Yesenvironmental cleaning is No state-wide program in No standardised state-wide No standardised state-wide Yes. Across all Victorian public
audited program in place (as of Jan company who use TOPCAT performed and compliance place. Cleaning assessments program in place. program in place. Hospitals as per the Cleaning
2012) but the release of the (Victorian Health audit tool) monitored as per Queensland are carried out at Royal Metropolitan hospitals monitor Most hospitals monitor and Standards for Victorian Health
new Environmental Cleaning Health-Cleaning Services, Policies, Darwin Hospital and evaluate cleaning services evaluate cleaning services at a Facilities, 2011 (first published
Policy and accompanying Standards and Operational at a hospital level. hospital level. 2000)
Environmental Cleaning Guidelines 2011
WA Country Health Plan to have hospitals perform
Standard Operating
(WACHS) has recently regular standardised internal
Procedures (ECSOP) expected
standardised their cleaning audits using a tool SA Health
during 2012 will provide step-
procedures including auditing will develop
by-step guidance and standards
for undertaking environmental
cleaning, including assessments,
in public healthcare facilities
across NSW

Visual Yes Yes Yes Yes Yes Yes Yes

assessment

Method of No standard audit tool or Data recorded either direct Data recorded either manually Data recorded manually (paper WACHSRisk assessments of No standard audit tool or Risk assessments of all
auditing methodology currently. onto electronic tool (paper based) or direct onto based) all functional areas with methodology currently. functional areas with auditing
Cleaning services are (TOPCAT) with direct entry electronic tool. auditing frequency and Cleaning services are frequency and acceptable
monitored and evaluated at a onto database (Environmental Pass or Fail reported for acceptable quality level (score) monitored and evaluated at a quality level (score) based on
hospital level Services staff) or manually via each question related to each based on the risk hospital level, using in-house the risk categorisation.
paper based system (Infection room element categorisation. Cleanliness developed tools, or by Pass or Fail reported for
Control) assessed as either Acceptable contractor as part of each question related to each
or Unacceptable agreement room element

Who performs Personnel designated at local Infection Control, Cleaning Operational Service Managers Infection Control personnel Hotel Services Personnel designated at local Internal auditshospital staff
audits hospital level Supervisors and Facilities and/or Infection Control hospital level from various departments who
Management have a good knowledge of the
Standards

Page 30 of 31
 NSW ACT QLD NT WA SA VIC

External auditsa qualified

Victorian Cleaning Standards
Auditor

Auditor Not currently No Not stated No No standardised training Not currently but standardised Yes
training training will be considered for
state-wide program

Areas audited Clinical areas Clinical areas All clinical and non-clinical Clinical areas WACHSall clinical and non- All clinical and non-clinical All clinical and non-clinical
areas clinical areas areas areas

Frequency of Dependent on local hospital Weekly Dependent on area: Biannual WACHSContinuous internal Varies between hospitals, but Continuous internal auditing
auditing Very high riskmonthly auditing with number of rooms at least annually in most with number of rooms audited
audited dependant on dependent on functional area.
High riskmonthly
functional area with annual Annual external audit.
Moderate riskbi-monthly
external audit
Results submitted to Health
Low riskquarterly
Department:

Internal auditstwo per

annum

External auditsannual

Yesmicrobiological swabbing
Other tools No No No No No No
used (not encouraged), White
Glove Method

Documented YesCleaning Service Standards, Yesthe cleaning company has YesQueensland Health- In progress WACHS: Yesstandardised Yesat hospital level YesCleaning Standards for
cleaning Guidelines and Policy for NSW its own policy and procedures Cleaning Services, Policies, cleaning protocols recently Victorian Health Facilities, 2011
protocols Health Facilities (1996) and Standards and Operational developed
Infection Control Policy Guidelines 2011
Directive (PD2007 036)

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