Disclosures: The authors report no relevant financial disclosures.
June 06, 2020
3 min read

Initiative improves daily, discharge cleaning in long-term care facilities

Disclosures: The authors report no relevant financial disclosures.
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A 3-month quality improvement initiative significantly increased the percentage of high-touch surfaces thoroughly cleaned throughout the day and at discharge in long-term care facilities in Brooklyn and Queens, New York, according to findings in Infection Control & Hospital Epidemiology.

“Colonization and infection with multidrug-resistant organisms is relatively common among residents of long-term care facilities (LTCFs), placing them at increased risk for the adverse outcomes that are associated with infection caused by these organisms,” David P. Calfee, MD, MS, chief hospital epidemiologist for NewYork-Presbyterian/Weill Cornell Medical Center, told Healio. “In the New York City area, carbapenem-resistant Enterobacteriaceae (CRE) and Candida auris have become prevalent in many LTCFs. Consultative and regulatory visits by the New York State Department of Health to some of these affected facilities had identified opportunities to improve infection control practices, such as environmental cleaning and disinfection, recommended to prevent transmission of these and other pathogens.”

According to Calfee, the Council of State and Territorial Epidemiologists and the CDC has announced a funding opportunity to support state health departments’ efforts to contain antimicrobial resistance, with an emphasis on CRE and C. auris. The New York State Department of Health (NYSDOH) obtained funding through this program for a regional quality improvement initiative among LTCFs in Brooklyn and Queens, NY.

“This initiative, which we describe in the article, was intended to improve the thoroughness of cleaning by providing education and training, resources and a forum in which participating LTCFs could share best practices and challenges and learn from and support each other,” Calfee added.

All LTCFs in Brooklyn and Queens, New York, were invited to take part in a 3-month quality improvement initiative organized by the NYSDOH and the Greater New York Hospital Association (GNYHA). Participating facilities were expected to fill out a questionnaire on current cleaning and disinfection practices, attend an in-person training session, participate in three follow-up conference calls and conduct two assessments of thoroughness of cleaning (TOC) with a fluorescent marking system. Facilities were permitted to choose the rooms and samples from 12 designated high-touch surfaces (HTS) to be evaluated by the GNYHA.

Of 106 LTCFs that were eligible, 48 (45%) enrolled in the study. At least one person from 38 LTCFs (79%) participated in the in-person meeting and representatives from 37 LTCFs (77%) completed the survey of baseline characteristics. The three subsequent conference calls were attended by 29, 27 and 24 participants, respectively.

According to the study, 32 facilities analyzed the TOC of 11,151 HTS in May and June of 2018. Of these, 8,418 (75%) were reported by facilities that supplied data in both rounds of data collection.

The percentage of HTS thoroughly cleaned during daily cleaning increased from 52% to 68%, for a 29% relative increase (P < .0001). For discharge cleaning, the researchers observed a 26% relative increase in thoroughly cleaned HTS (74% vs. 59%; P < .01). According to the study, the TOC differed substantially among individual HTS and LTCFs. Among LTCFs, thorough daily cleaning ranged from 6% to 100% and from 28% to 100% during the first and second rounds of data collection, respectively, whereas rates of thorough cleaning at discharge ranged from 11% to 91% and from 41% to 100% during the first and second rounds, respectively.

Frequent challenges during site visits included lack of knowledge among environmental services workers (ESWs) and clinical staff about necessary contact time for disinfectants used in the facility, poor allocation and understanding of responsibility for cleaning and disinfection of medical equipment, clutter in resident rooms that prevented thorough cleaning, tears in furniture coverings and furnishings that were difficult to clean, and workloads for ESWs that were described as often unrealistic.

“However, we also identified several ‘best practices’ and effective approaches to improve cleaning, disinfection and adherence to other important infection prevention strategies that could be shared among facilities,” Calfee said.

According to the study, these best practices included systems that enable personnel to easily differentiate clean from dirty equipment, using disposable blood pressure cuffs and dedicated sphygmomanometers for residents colonized with C. auris, prominent display of contact precautions signage with visual aids and frequent interdepartmental communication about contact precautions.

“The findings suggest that, with relatively few additional resources, education and objective assessment and feedback, cleaning and disinfection in LTCFs can be improved. However, there is much more to learn and much more to do to eliminate barriers that LTCFs face in their efforts to prevent pathogen transmission,” Calfee said. “More research is needed to determine if this type of intervention is effective in other LTCFs and if the improvements observed during the relatively short project period are sustainable over longer periods of time.”

Future research and quality improvement initiatives are necessary to assess the impact of improvements in cleaning and disinfection on pathogen transmission and infection among residents of LTCFs, according to Calfee.