Greening of hospitals workshop cleaning studies

GREENING OF HOSPITALS WORKSHOP

Cleaning of Surfaces in Patient Care Areas

Results From New Hospital Studies

Two Paradigm Shifts in Patient Room Cleaning 1st Going from the string mop to the flat mop

system for floor cleaning 2nd Moving from cleaning patient areas with a

detergent + disinfectant to a detergent-free cleaner + bleach

Using Flat (Microfiber) Mopping Systems in Hospitals

Paradigm Shift #1

Take Home Message1. Practical, common-sense

approach for patient care areas, but WILL NOT meet all mopping needs.

2. Immediate water and chemical savings, but most cost savings are a result of reduced labor.

3. Improved ergonomics and cross-contamination infection control

4. Proactively address potential hurdles to implementation.

Mopping Requirements

Patient care areas cleaned daily; common areas cleaned more often

Floor cleaners can contain dangerous chemicals

Special precautions required to avoid cross-contamination

Why Hospitals Switch to Flat Mopping Systems

Ergonomic issues

Labor savings

Reduced chemical and water usage

Cross-contamination concerns related to conventional mopping

What is Microfiber?

Split wedged shape of Polyester fiber

Split wedged shape of Polyester fiber

1/100th of human hair1/100th of human hair

…and what difference does it make for mopping?

Increases the effective surface area of your mop

More effective in cleaning up especially small particles

Microscopic fibers thoroughly clean surfaces

Flat Mopping Systems: How Do They Work?

1. Place

2. Mop

3. Peel

4. Launder

vs. Conventional Loop Mops

1. Dip and Wring

2. Mop

3. Repeat 3x

4. Change Water

5. Send to Industrial

Laundry

Ergonomic Benefits

During use, similar gross motor skills required

Unfavorable positions for both methods, but flat mopping systems significantly reduced the frequency and severity of the risk factors

“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

Ergonomic Analysis


Tasks String Mopping Flat Mopping

Lift empty metal/plastic bucket from cart

Lift metal bucket (5 lbs) Trunk flexion 60°

Lift plastic basin (1 lbs) Trunk flexion neutral

Carry empty bucket/basin and walk 3 feet

Forces at trunk, shoulders, elbow, hands (carrying 5 lbs)

Negligible forces (carrying 1 lb)

Fill and lift bucket/basin

Forces acting on neck, back, hands, wrist, shoulders (water 16 lbs)

Less forces acting due to lower weight (8 lbs)

Lift bucket of water, walk to cart

Flexion of trunk, hips, knees, shoulders. Forces at trunk, wrist, shoulder, elbow

Upper body posture is neutral; less forces acting on trunk, wrist, shoulder, and lower body

Ergonomic Analysis


Carry bucket of water, walk to cart

Forces at trunk, wrist, shoulder, and elbow

No longer performed

Lift bucket of water and place on cart surface

Wrist and elbow flexion. Forces acting as previously.

No longer performed

Walk to closet for bottle of cleaning solution on shelf. Reach and grasp.

Neck extension, hips flexion, shoulder flexion 120°

Same

Add cleaning solution and replace bottle on shelf

Neck extension, hips flexion, shoulder flexion 120°

Same


Ergonomic Analysis


Pick up wringer and hook it onto lip of bucket

Trunk flexion 80°, elbow flexion 60°, shoulders flexion 80°. Forces acting at trunk.

No longer performed

Push cart to room, distance 25’

Walking with trunk flexion 30°, shoulder and elbow flexion 80°. Forces acting at trunk.

Walking with trunk flexion neutral. Pushing cart with standard equipment.

Remove excess water from mop

Palmar grasp, shoulder elevation and flexion, elbow flexion (using mop wringer)

Wring cloth, wrist/hand twisting with grip force


Ergonomic Analysis


Mopping the floor Trunk flexion Trunk flexion

Mopping the floor

Place mop in bucket of water, wring, and continue mopping. Same risks as previous steps

Turn mop head downside up and replace cloth at mop head


Microfiber Considerations

Non-industrial washing machines must be used to wash microfiber mop

heads

Cannot be used in areas contaminated with blood or body fluid

Some products ineffective in greasy, high traffic kitchen areas

Sticky floors?

CA DHS – Licensing and Certification March 2002 Memo:

“…acceptable to install household washing machines to launder

microfiber mops…”

provided: Water Temp between 130 and 140

degrees F Separately from other textiles No bleach/fabric softener

“…as long as (these conditions) are met, there should be no infection control related issues.”

Not All Mopping Systems are Created Equal…

No governing body or industry definition of “microfiber”

Density of fibers per square inch can affect pricing and cleaning ability

…vs denier (diameter of fiber)

Some are pretreated with antimicrobials

Should I Use Disinfectants for Cleaning Floors?

Some microfiber products are treated with triclosan or other antimicrobials

Concerns about general use of antimicrobials

Potential for causing antimicrobial resistance

Unknown long term consequences of its use

How many mops handles/heads needed?

Mop Handles = Number of Janitors

Mops Heads =

+twice the number of rooms cleaned daily

+“shrinkage”

+special circumstance – large rooms, extra dirty rooms

Case Study: University of California Davis Medical Center

Reasons for change…

Increase in worker’s compensation claims

Frequent “light duty” ergonomic requirements

Reduce cleaning time for patient rooms

Reduce chemical use and disposal

Cost Analysis: Lifetime Mop Costs

Conventional Wet Loop Mops

$5 each

55 to 200 washing lifetime

22 rooms cleaned per washing

$0.11 to $0.41 per 100 rooms

$4.00 each

500 to 1,000 washing lifetime

1 room cleaned per washing

$0.40 to $0.80 per 100 rooms

Microfiber Mops

Cost Analysis: Chemical Costs


10.5 ounces per day

$0.22 per ounce

20 rooms cleaned per day

$11.55 in chemicals per 100 rooms

0.5 ounces per day

$0.22 per ounce


$0.50 in chemicals per 100 rooms

Microfiber Mops

Cost Analysis: Water Use


21 gallons per day


105 gallons of water used per 100 rooms

1 gallon per day


5 gallons of water used per 100

rooms

Microfiber Mops

Cost Analysis: Labor Costs


20 rooms cleaned per 8 hour shift

$12 per hour

$480 per 100 rooms

22 rooms cleaned per 8 hour shift

$12 per hour

$436 per 100 rooms

Microfiber Mops

Flat Mopping Systems Performance Summary

Microfiber last 5 to 10 times longer

Increase production by 10%

Use 95% less chemical

(2.5 vs. 53 ounces per 100 rooms cleaned)

Use 95% less water

(5 gals vs. 105 gals per 100 rooms cleaned)

Overall costs about 5-10% less - not including workers comp savings

Costs/Benefits That Are Not Quantified Reduced risk of

cross-contamination related to mopping

Reduced worker’s compensation claims

Reduced water use

Patients say: “quieter, quicker, less disruptive”

Discussion

1. Who’s currently using microfiber mops?

2. How satisfied are you with them in patient care areas?

3. What hurdles did you have to overcome?

4. What have you seen as the greatest benefit to using microfiber mops?

Take Home Message1. Practical, common-sense approach

for patient care areas, but WILL NOT meet all mopping needs.

2. Immediate water and chemical savings, but most cost savings are a result of reduced labor.

3. Improved ergonomics and cross-contamination infection control

4. Proactively address potential hurdles to implementation.

Resources

EPA Factsheethttp://www.epa.gov/region/waste/p2/projects/hospital/mops.pdf

Sustainable Hospitals 10 reasons to use microfiber mops

http://www.sustainablehospitals.org/PDF/tenreasonsmop.pdf

Practice Greenhealth http://www.h2e-online.org/docs/h2emicrofibermops.pdf

The Need for Action

The number of Healthcare Acquired Infections is too high

Even with interventions: Hand hygiene education Gel stations installed throughout patient care areas Closer oversight of drug administration

HAIs and associated deaths continue Cost of a patient room runs $9,462 per day

Unnecessary Deaths: The Human and Financial Cost of Hospital Infections

By Betsy McCaughey, Ph.D. HAIs are the fourth largest killer in America HAIs add an estimated $30.5 Billion to the cost of

healthcare in the US each year There is compelling evidence that nearly all

HAIs are preventable This creates a new legal issue

Estimated Hospital Cost of HAIs

2,000,000 Estimated HAIs per year in USA

X

$15,275.69 Average additional hospital costs per HAI

= $30.5 Billion Per year treating HAIs

Cleaning is Essential Cleaning hands is the first step – preventing

recontamination is the second Two studies showed that over half of objects

that should have been cleaned or disinfected were overlooked

As long as surfaces in a hospital are not cleaned, caregivers’ hands will be recontaminated

Cleaning of Environmental Surfaces is Essential

Cleaning of environmental surfaces is so important that if not done properly, the placing of a patient into a room previously occupied by a patient with C-diff can be a fatal error

Studies of Patient Room Cleaning Studies undertaken by HospAA of two-step

cleaning process Studies measured the current cleaning prior

to implementing the two-step cleaning process Current process used cleaners with quaternary

ammonium disinfectant This process leaves a residue that can lead to a

biofilm

Paradigm Shift #2 Two-Step

Cleaning First step: Clean to remove biofilm with non-detergent cleaner that contains 218 ppm bleach Sodium Chloride is used to soften water Sodium Citrate is used to chelate hard water mineral

deposits Sodium Carbonate is used to saponafy organic soils into

soaps that are easily rinsed Sodium Bicarbonate is used as a builder and sequester

Second step: Wipe the 14 HROs with bleach of 1,000 ppm

How Detergent-Free Cleaners Work

Cleaning is defined as: the ability to clean or remove soil from a surface

Accomplished by one or more of the following Lowering surface and interfacial tensions Solubilization of soils Emulsification of soils Suspension of removed soils Saponification of fatty soils Inactivation of water hardness Neutralization of acid soils

Background for Studies

Used luminometers manufactured by 3M to measure adenosine triphosphate (ATP)

ATP measured in relative light units (RLUs) The 14 high risk objects (HROs) outlined by

Dr. Philip Carling in his studies were measured

ATP Luminometer

Carling’s 14 High Risk Objects Objects:

Sink Toilet Seats Over Bed Tray Bed Side Table Toilet Handle Bed Side Rail Nurse Call Box

Visitor Chair Arm Rest Patient Telephone Rest Room Door Knob Restroom Hand Rail Bedpan Cleaner Patient Room Door Knob Restroom Light Switch

Using the ATP Swab

Results of Studies Three hospitals: Tested a minimum of 25 terminally

cleaned rooms in Phase I 1,011 measurements made of the 14 HROs

Mean Measurement was 441 RLU Worst HROs:

Nurse Call Box 900 RLU (N=75) Patient Telephone 742 RLU (N=68) Visitor Chair Arm Rest 624 RLU (N=75) Bedside Rail 503 (N=77) Rest Room Door Knob 489 RLU (N=53) Sink/Counter 445 RLU (N=79) Rest Room Hand Rail 411 RLU (N=76)

Efforts to Standardize Studies Attempted to measure a minimum of 25

terminally cleaned rooms in each phase No disturbance of patients The room was ready for re-occupancy

Trained staff doing ATP measurements Uniformity in swabbing Focused on the worst of Dr. Philip Carling’s 14

HROs Sampled with staff and monitored results

Results From Four Hospitals Phase I (cleaner/quaternary ammonium

disinfectant) (N= 408) Worst Five measured at each facility Mean 1,360 RLU (r=468 RLUs – 2,290 RLUs)

Phase II (DFC + bleach) (N= 412) Mean 143 RLU (r=89 RLUs – 199 RLUs)

Four Hospital Study Results

HRO RLUs Before* RLUs After*

(Phase I) (Phase II)

Restroom Door Knob 1,934 89

Nurses Call Box 2,290 143

Patient Telephone 1,126 104

Bed Side Rail 983 164

Visitor Chair Arm Rest 1,045 199

Restroom Hand Rail 486 143

Sink/Counter 468 127

* These are Mean scores in RLUs

Four Hospital Cleaning Study

0

500

1,000

1,500

2,000

2,500

NURSE CALL BOX VISITOR CHAIR ARMREST

PATIENT TELEPHONE BED SIDE RAIL RESTROOM HANDRAIL

RESTROOM DOORKNOB

SINK/COUNTER

High Risk Objects (HROs)

Rel

ativ

e L

igh

t U

nit

s (R

LU

s)

Prior Cleaning

Two-step Cleaning

Percent of Samples Found “Clean” A surface is deemed to be clean at a reading

of 250 RLU or less using the 3M luminometer Results from the four hospital studies:

Phase I: Found 25.0% were below 250 RLU Phase II: Found 87.4% below 250 RLU

Four Hospital Cleaning Study

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

<250 RLUs 250 - 499 RLUs 500 - 999 RLUs ≥1,000 RLUs

Relative Light Units (RLUs)

Per

cen

t

Prior Cleaning

Two-Step Cleaning

Future Patient Rooms

Continuous Improvement

Train EVS staff in use of DFC + bleach Use ATP monitoring to measure change Continue use of ATP monitoring for training

and quality assurance Monitor HAIs Develop a Process Improvement Story

Business

Greening of hospitals workshop cleaning studies