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      Impact of Educational Intervention on Cleaning and Disinfection of an Emergency Unit

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          Abstract

          We aimed to evaluate the impact of an educational intervention on the surface cleaning and disinfection of an emergency room. This is an interventional, prospective, longitudinal, analytical and comparative study. Data collection consisted of three stages (Stage 1—baseline, Stage 2—intervention and immediate assessment, Stage 3—long term assessment). For the statistical analysis, we used a significance level of α = 0.05. The Wilcoxon and the Mann–Whitney test tests were applied. We performed 192 assessments in each stage totaling 576 evaluations. Considering the ATP method, the percentage of approval increased after the educational intervention, as the approval rate for ATP was 25% (Stage 1), immediately after the intervention it went to 100% of the approval (Stage 2), and in the long run, 75% of the areas have been fully approved. Stage 1 showed the existence of significant differences between the relative light units (RLU) scores on only two surfaces assessed: dressing cart ( p = 0.021) and women’s toilet flush handle ( p = 0.014); Stage 2 presented three results with significant differences for ATP: dressing cart ( p = 0.014), women’s restroom door handle ( p = 0.014) and women’s toilet flush handle ( p = 0.014); in step III, there was no significant difference for the ATP method. Therefore, conclusively, the educational intervention had a positive result in the short term for ATP; however, the same rates are not observed with the colony-forming units (CFU), due to their high sensitivity and the visual inspection method since four surfaces had defects in their structure.

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          The role of the surface environment in healthcare-associated infections.

          This article reviews the evidence demonstrating the importance of contamination of hospital surfaces in the transmission of healthcare-associated pathogens and interventions scientifically demonstrated to reduce the levels of microbial contamination and decrease healthcare-associated infections.
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            Finding a benchmark for monitoring hospital cleanliness.

            This study evaluated three methods for monitoring hospital cleanliness. The aim was to find a benchmark that could indicate risk to patients from a contaminated environment. We performed visual monitoring, ATP bioluminescence and microbiological screening of five clinical surfaces before and after detergent-based cleaning on two wards over a four-week period. Five additional sites that were not featured in the routine domestic specification were also sampled. Measurements from all three methods were integrated and compared in order to choose appropriate levels for routine monitoring. We found that visual assessment did not reflect ATP values nor environmental contamination with microbial flora including Staphylococcus aureus and meticillin-resistant S. aureus (MRSA). There was a relationship between microbial growth categories and the proportion of ATP values exceeding a chosen benchmark but neither reliably predicted the presence of S. aureus or MRSA. ATP values were occasionally diverse. Detergent-based cleaning reduced levels of organic soil by 32% (95% confidence interval: 16-44%; P<0.001) but did not necessarily eliminate indicator staphylococci, some of which survived the cleaning process. An ATP benchmark value of 100 relative light units offered the closest correlation with microbial growth levels <2.5 cfu/cm(2) (receiver operating characteristic ROC curve sensitivity: 57%; specificity: 57%). In conclusion, microbiological and ATP monitoring confirmed environmental contamination, persistence of hospital pathogens and measured the effect on the environment from current cleaning practices. This study has provided provisional benchmarks to assist with future assessment of hospital cleanliness. Further work is required to refine practical sampling strategy and choice of benchmarks. Copyright © 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
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              Use of audit tools to evaluate the efficacy of cleaning systems in hospitals.

              Recent publicity has highlighted both the inadequacies of hospital cleaning and high levels of methicillin-resistant Staphylococcus aureus infections in UK hospitals. "Standards for Environmental Cleanliness" (SEC) was a checklist developed in April 1999 by the Infection Control Nurses Association and the Association of Domestic Managers to evaluate cleaning services regardless of who is the provider. More recently, the National Health Service plan (July 2000) was an attempt to generate a rapid improvement in the cleanliness and tidiness of hospitals via a National Health Service patient environment audit (PEA). On the basis of models used in the food industry to manage cleaning practices cost-effectively, a risk-based audit checklist incorporating rapid hygiene monitoring was developed to assess the adequacy of cleaning programs and standards in hospitals. This checklist (Audit for Cleaning Efficacy, or ACE) as well as the SEC and PEA approaches were applied at 4 hospitals, and environmental microbial surface counts were compared. SEC and PEA rely on visual assessment, whereas the ACE approach is more comprehensive and included more specific questions relating to the management and monitoring of cleaning as well as standards on the basis of rapid hygiene monitoring. Two wards in each of the 4 hospitals were visited on 3 separate occasions immediately after cleaning was completed. Visual assessment, adenosine triphosphate bioluminescence, and microbiologic sampling of selected environmental sites were performed to evaluate the effectiveness of cleaning. The 3 audits were completed during the final hospital visit. Visual assessment indicated that 90% of sites were satisfactory, whereas adenosine triphosphate bioluminescence showed that 100% and microbiologic sampling showed that 90% of sites did not meet benchmark values. There was no significant difference between the SEC and PEA audits (P =.311), which used visual assessment, and the results suggest that they both are similar in passing surfaces that have microbiologic benchmark values that are too high. However, the ACE audit showed a significant difference (P = <.001) in results compared with the SEC and the PEA audits and did not pass surfaces with microbiologic benchmark values that were too high. The ACE audit, which incorporates rapid hygiene testing, showed a much stronger association with the microbial counts; this was not apparent with the SEC and the PEA audits. The data suggest that visual assessment is a poor indicator of cleaning efficacy and that the ACE audit gives a better assessment of cleaning programs compared with the other 2 audit methods in relation to microbial surface counts. It is recommended that hospital cleaning regimes be designed to ensure that surfaces are cleaned adequately and that efficacy is assessed with use of internal auditing and rapid hygiene testing.
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                Author and article information

                Journal
                Int J Environ Res Public Health
                Int J Environ Res Public Health
                ijerph
                International Journal of Environmental Research and Public Health
                MDPI
                1661-7827
                1660-4601
                09 May 2020
                May 2020
                : 17
                : 9
                : 3313
                Affiliations
                [1 ]Campus Três Lagoas, University of Mato Grosso do Sul, Três Lagoas 79600-080, Brazil; bruna.andrade1994@ 123456gmail.com (B.A.d.S.O.); lucasbernardes88@ 123456gmail.com (L.d.O.B.); a.amr@ 123456ig.com.br (A.M.F.); juliana@ 123456pessalacia.com.br (J.D.R.P.); maracristina.mga@ 123456gmail.com (M.C.R.F.); airesjr_@ 123456hotmail.com (A.G.d.S.J.)
                [2 ]Network in Exposome Human and Infectious Diseases (NEHID), School of Nursing of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14040-902, Brazil; dandrade@ 123456eerp.usp.br
                [3 ]Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal; luis.lapao@ 123456ihmt.unl.pt
                [4 ]Paulista School of Nursing, Federal University of São Paulo, São Paulo 04023-062, Brazil; dulce.barbosa@ 123456unifesp.br
                Author notes
                [* ]Correspondence: alvarosousa@ 123456usp.br
                Author information
                https://orcid.org/0000-0003-2710-2122
                https://orcid.org/0000-0002-9912-4446
                Article
                ijerph-17-03313
                10.3390/ijerph17093313
                7246614
                32397527
                faa3ffb5-8f2e-44d9-ab44-19f271f0981c
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 28 February 2020
                : 17 April 2020
                Categories
                Article

                Public health
                infection control,hospital cleaning service,cleaning products,feedback,disinfection,patient safety,continuing education

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