A nurse enters the room to administer a medication that requires accessing the patient’s central line. To do this, the nurse places the supplies on the bedside table and proceeds to perform hand hygiene and don clean gloves. Next, the nurse retrieves the supplies from the bedside table and proceeds to access the central line to administer the medication.
Even if the nurse performs good central line hub asepsis, there is still a risk of cross contamination via the central line from organisms living on the bedside table that have been transferred to the supplies and the nurse’s gloves. Cross contamination may be prevented by handwashing, aseptic and sterile techniques, and high-touch area cleaning methods.
In a patient room, the high-touch area environment consists of surfaces in the room that the patient, visitors or health care personnel frequently touch or use, such as the bedside table. Cross contamination increases a patient’s risk of a hospital acquired infection (HAI).
Like most pediatric hospitals, for the last decade or more, Children’s Health in Dallas, Texas, has set out to eliminate HAIs, such as central line associated blood stream infections (CLABSI) by implementing prevention bundles and focusing on high reliability practices. As a result, the hospital has achieved and sustained low CLABSI and catheter associated urinary tract infection (CAUTI) rates. However, the hospital is not at zero.
Despite the use of standardized cleaning methods by Environmental Services (EVS) personnel during routine room turnover and for patients with infections, Children’s Health recognized an opportunity to test a standardized approach to high-touch area cleaning to prevent cross contamination to help get closer to that goal.
Collaboration with EVS personnel as well as Infection Prevention and Control (IPC) was essential to help the hospital better understand cleaning techniques and approaches to cleaning an occupied patient room.
First, a process map was created that identified areas of the room EVS cleaned, how often the areas were cleaned, and the cleaning products used. A CLABSI workgroup used the process map to identify gaps or inconsistencies in cleaning practices. Surfaces often used to place patient belongings, medications and related supplies or hospital equipment were identified as gaps.
Based on the gap analysis, the following surfaces were identified as high-touch areas:
- Infusion/feeding pump and pole
- Cardiac/respiratory monitors and cables
- Nurse call light
- Bedside table
- Sink, fixtures and adjacent counter space
- Bed rails, head/foot board
In addition, EVS personnel reported these surfaces were often not cleaned because of their discomfort with moving patient belongings or the limitation of not being allowed to move medical equipment.
Finding the right frequency for cleaning
Next, the organization determined how often cleaning needed to occur, how the team would monitor compliance of this new process and connect it with patient outcomes. To determine the frequency of cleaning, the team partnered with IPC who recommended cleaning at least once per 12-hour shift and as needed for emesis or spills. This recommendation was made because bacteria, viruses and fungi live on surfaces for varying lengths of time.
Documentation for high-touch area cleaning was developed and implemented in the electronic medical record. A documentation report was then created to assess compliance with high-touch area cleaning. The report is broken down by unit and shift and helps identify potential gaps in practice as well as potential action items when the team investigates HAIs.
Results of new cleaning practices
In 2016, the team selected the inpatient Hematology/Oncology and Gastroenterology (GI) units as areas to pilot the new practices. Prior to high-touch area cleaning, 2016 CLABSI rates were:
- 0.8 per 1,000 catheter days on Hematology/Oncology.
- 1.4 per 1,000 catheter days on the GI unit.
In 2017, after implementation of high-touch area cleaning in the two pilot units, CLABSI rates decreased to:
- 0.5 per 1,000 catheter days in Hematology/Oncology.
- 0.8 per 1,000 catheter days in the GI unit.
Sustainability can be difficult to achieve, and in 2018, each area experienced a slight increase in CLABSI rates:
- 1.1 per 1,000 catheter days in Hematology/Oncology.
- 1.3 per 1,000 catheter days in the GI unit.
Re-education was completed to help hardwire the process while continuing staff engagement and awareness on the importance of high-touch area cleaning.
Education for staff about high-touch cleaning
Based on the pilot results, the CLABSI Steering Committee approved system wide implementation of high-touch area cleaning. In November 2017, education on high-touch area cleaning, including documentation, was provided to nurses and non-licensed clinical staff. The education consisted of a computer-based training module, a video to demonstrate the process and a quick reference job aid.
Once education was complete, compliance metrics were disseminated and transparent to all hospital leadership as well as reviewed in CLABSI steering and workgroup meetings. Compliance was evaluated for once-a-day cleaning and once-a-shift cleaning to continue to assess potential follow up needs or reinforcement.
During the implementation phase, several strategies were used to hardwire high-touch area cleaning:
- Just-in-time reinforcement of education.
- Presentations at hospital leadership meetings.
- Sharing evidence-based articles on the topic.
- Quality newsletter highlights.
One reinforcement strategy used to assist with hardwiring the new procedure was called, “Don’t get caught with the card.” A postcard was created with information on high-touch environment cleaning for each unit. Bedside nurses on each unit were responsible for sharing information on high-touch area cleaning with a nursing peer and then give the postcard to the peer nurse so he or she can share the information with another peer. The goal of the reinforcement strategy was to not get caught with the card.
Other unit-specific strategies included annual performance goals, chart audits and one-on-one coaching to improve accountability. As a reward, the Quality Department hosted a celebration for the unit that demonstrated the greatest improvement in compliance.
Hardwiring the process
Compliance with this new process was measured using all-or-none methodology, meaning every component of the high-touch area bundle must be performed and documented to be compliant. Following the education rollout, initial compliance with once-a-day cleaning was 61% and increased over time to 98% system wide. While this is important, the goal was to perform high-touch area cleaning twice a day, once per 12-hour shift.
In July 2018, the organization started sharing compliance reports for twice-a-day cleaning. Initial compliance with twice-a-day cleaning was 38% but slowly increased over the course of the year to 78% by July 2019. Despite the slow uptake, compliance rates, in general, demonstrated an upward trend on every campus as well as in units with high central line volumes.
Seeing a decline in bloodstream infection rates
Even though it took time to hardwire the practice of high-touch area cleaning into the routine daily tasks of health care personnel, the organization has seen a return on investment in this practice. For example, HAI rates continue to decline:
- Before implementation in 2016, the system level CLABSI rate was 1.1 per 1,000 central line days.
- After implementation in 2018, the system level CLABSI rate was 0.9 per 1,000 central line days.
- In 2016, the CAUTI rate on the largest inpatient campus was 1.3 per 1,000 catheter days.
- In 2018, the CAUTI rate on the same campus was 0.5 per 1,000 catheter days, a more than 60% decrease.
In addition to the CLABSI and CAUTI rates, across the organization there has been a declining trend in respiratory HAIs. In 2018, after a full year of implementation:
- The organization had a mean rate of 9.7 respiratory HAIs per 10,000 patient days.
- In 2019 the rate through April was 7.4, a more than 20% reduction.
While a direct correlation with this improvement initiative and these outcomes can’t be made, this practice is contributing to the reduction of HAIs in each of our three hospitals.
The organization identified the need to outline a standard approach to high-touch area cleaning but encountered some obstacles along the way. First, there is variation from unit to unit and from hospital to hospital in the set-up of hospital rooms—a standard acute care services’ room is different than a neonatal intensive care unit room.
The variation among rooms and surfaces had to be clarified including appropriate documentation for those who were performing high-touch area cleaning. Next, the organization clarified who among the unit-based health care team was cleaning what surfaces in the room. For example, registered nurses clean the infusion/feeding pumps and poles while non-licensed clinical staff clean the remainder of the high-touch surfaces in the room.
A takeaway from this initiative is the value of creating a standardized approach to high-touch area cleaning that was implemented across the organization to ensure all high-touch surfaces were adequately cleaned. Another takeaway is the value of collaboration with EVS.
This partnership helped reinforce the organizational mission: to make life better for children because reducing the risk of harm is everyone’s responsibility. Engaging EVS leaders and staff as well as other support staff in a quality improvement initiative was beneficial to the success of this project.
The journey to find ways to eliminate HAIs and achieve zero patient harm continues. Once the organization achieves and sustains high reliability with high-touch area cleaning strategy, the next step is to expand it to place medical supplies and medications on prep pads in a patient room. In addition, the hospital plans to expand the focus of high-touch area cleaning to high-touch areas outside of the patient room, such as places that families frequently use.