Every year in Canada, more than 200,000 patients acquire infections when receiving healthcare, and 8,000 die as a result, according to the Public Health Agency of Canada. These statistics show the importance of quality cleaning audits, as 80 per cent of common infections are spread by healthcare workers, patients and visitors. However, these high numbers also reveal the amount of work that has yet to be accomplished.
Unfortunately, many facilities are not performing quality audits often enough to meet cleaning and disinfecting goals, which also applies to schools and the hospitality industry in general. This issue, among many, was highlighted at the Canadian Association of Environmental Management’s (CAEM) Taking Action: Conference and Trade Show recently held in Alliston, Ontario.
During a three-part panel discussion on new cleaning audit tools and technologies, Dr. Patrik Marchand, project manager in the research and development department at Sani Marc-Wood Wyant, said that most sites claim they don’t have time to perform audits on a regular basis; however, measurement is key in order to help spot deficiencies and prevent infections, including those caused by antimicrobial resistance.
“Even if a place looks clean, it might not be clean,” he said to a room of conference goers, before emphasizing that a good audit should be transparent, easy to use and offer quick results.
With such issues in mind, Marchand, along with Dean Waisman, president of Westech and director of education for CAEM, and Diane Richards, director of product development at Charlotte Products LTD, showcased new innovations in cleaning audits and offered expert advice to help with facility management.
Cleaning Audits: Benefits and Necessary Components
The panel discussed the importance of cleaning audits and listed fundamental items all auditing systems should possess. While much of the talk focused on healthcare, the information is applicable to all types of facilities.
Cleaning measurement should not only be an objective process that ensures cleaning staff is accountable to their contractual obligations, but should also highlight good performance to motivate staff. Marchand noted that a successful audit should also identify improvement areas early on to prevent costly outcomes. Finding insufficiencies in buildings and equipment, not just staff, will also help managers understand what equipment is tougher to clean and more subject to contamination.
Auditing tools from Visual, UV Markers, Observational or ATP systems offer many benefits for the healthcare industry, noted Waisman. They extend to infection control, forming public perception and confidence in a facility, boosting morale of staff and improving healing in patients, supporting a preventative maintenance program and helping supervisors get the most from building service contractors, while training them in a positive manner.
“We all know budgets have been cut and there is not a lot of money in healthcare for cleanliness, so you really want to get the best bang for your buck from the housekeeping staff or contract cleaning company,” said Waisman. “A great auditing program can help ensure everything is getting done properly.”
Important components all systems should have include established standards like PIDAC in Ontario and PICNET in B.C., for example.
“It’s all about consistency at the end of the day,” said Waisman. “If you’re doing any type of auditing, you really need to have very specific ways of doing it so everybody is doing it the same way.”
Hands-on training is also important, along with an independent component, such as a third party auditor to ensure better results.
“Last thing you want is an auditor who is roaming around your halls passing or failing everything,” he said. “If he’s failing everything, it’s not fair to the housekeeping department or the staff, and if he’s passing everything, it’s not fair to the patients because infection control is a risk.”
That said, if a facility doesn’t have an independent component, it needs a mechanism in place to help an auditor provide accurate results in an objective manner.
“If you don’t have that independent component or mechanism in place, scores will literally be 10 per cent higher from what they are in reality,” he stressed. “You also need some sort of technology so results don’t end up on the floor – a web-based system that puts everything in one place.”
ASSURE Audit Tool
Despite the lack of quality cleaning audits being performed on a regular basis, industry innovators are developing more accessible and cost-effective tools.
ASSURE, a new tool on the market, developed by Marchand through Sani Marc -Wood Wyant, is a simple way to help managers identify whether quality cleaning products and practices are effective in schools, hospitals, hotels, offices, retail and all other commercial buildings.
Visual audits are the most common practice in Canada, and an inspector might wrongly give a pass to a room he or she sees as being clean, when it’s not. ASSURE system is a new patent-pending quality assurance audit tool that comes in two components: a tracer (blue bottle) and a detector (yellow bottle), along with follow-up tools.
At 300 tests per bottle and a few cents per test, the system is cost-effective and easy to carry around from facility to facility. The ASSURE TRACER can be applied to most surfaces prior to cleaning by the supervisor. It dries quickly and leaves no residue, and once the cleaning is complete, the supervisor can apply ASSURE DETECTOR to the surfaces marked with the TRACER. If the surface is clean, there will be no reaction, but if the surface is dirty, a strong, white foam will appear. From there, a supervisor can record the results and suggest further actions. As a follow-up, ASSURE Report, free and complementary to the system, allows supervisors to record results using a smartphone to build a database for examining results to improve outcomes.
OptiSolve Pathfinder, a patented quality monitoring tool that directly uses a smartphone camera and interface, is basically an iPhone that requires a proprietary DNA tracker to work in conjunction with the camera filters.
It directly measures live bacterial DNA, said Richards, who presented the new innovation to the industry in the room. She helped develop the technology through Swish Maintenance, part of Charlotte Products.
Swish Maintenance is a privately-held family business globally headquartered in Peterborough, Ontario. It has provided services for the janitorial and sanitation industry for more than 60 years. Two years ago, a new division of Swish Maintenance called OptiSolve was formed. It revolves around fundamental research and development that brings first-to-market technology to help solve the toughest cleaning challenges.
With OptiSolve Pathfinder, users just have to press a button, but Richards says the algorithms and science behind the calculating—making sure bacteria is actually seen—is highly sophisticated. The technology will generate an actual image and an intensity map that gives a quantifiable scale, much like an ATP reader would. It also has a very low cost of data capture enabling frequent or more data intensive studies. The cost of capture of an image using the DNA tracker is estimated at 20 cents per image.
“Most importantly, it provides critical insights to improve infectious disease management,” said Richards.
The OptiSolve division utilized one of four microscopy systems in the world, which is based at the University of Toronto and valued at about $10 million. The system included specialized biofilm chambers where Richards and other researchers could see how biofilms organize. They were able to see different chemistries and miniaturize all their learnings into a smartphone.
“Every facility is completely different and every facility manager is completely different, and the degree to which you have infection development professionals at your support is completely different,” noted Richards. “Like your smartphone, how you want to use it is up to you. The platform is as important as what we see.”
To present a visual, Richards flashed various photos that highlighted where bacteria could be found post cleaning, for example, on doorknobs and water fountains. After the fixtures are sprayed with the DNA market treatment, specific colours indicate results ranging from no detected bacteria to high levels of bioburden and bacteria. Bioburden is normally defined as the number of bacteria living on a surface that has not been sterilized.
In one photo, high levels of bioburden and bacteria were detected on a push button of a water fountain—around the raised lettering of the branding. Despite the fact the fountain had been cleaned with standard protocol, the technology helps auditors understand where the source risk is coming from.
Currently, Swish Maintenance has more technology under development, such as a tracker system to specifically look for markers that indicate high levels of biofilm, and a spray that can be used to find Clostridium difficile (C. diff), a common healthcare-associated infection that has more than tripled in Canada since 1997, according to the Public health Agency of Canada.
Visual, UV Marker, Observational and ATP systems
A visual audit, or what Waisman calls “a white-glove test on steroids,” can include a number of products and processes. Westech, a leader in performing independent cleaning audits, suggests a few methods that will, ultimately, help benchmark different facilities and allow supervisors to access how well a facility is performing overall in all risk areas.
“I’ve been in hundreds of hospitals across Canada and the sad truth is we’re not at a point that we’re 100 per clean—where we can toss away the visual audit program,” he said. “It’s still your best line of defense.”
Westech uses products like an extending mirror and flashlight to examine hard-to-reach surfaces, such as underneath beds in residential care facilities with limited lighting, and huggie wet wipes are used for frequently touched surfaces.
“I’ve been in an exam room and looked at an exam bed that seemed perfectly clean to the naked eye,” he said. “You take one of these wipes to it and it will be soiled. It’s a way of assessing the surface.”
Visual audits should also be available on an iPhone or iPad – auditors can download the databases for their hospitals. Everything is in a dropdown menu, and all the calculations are completed. Audits are transmitted to the web and disseminated to the proper people in real time. Good visual audit programs also need three days of training, including a certification program with tests and a one-on-one assessment.
UV Marking, easy to apply and good for benchmarking from facility to facility, involves putting an invisible power or gel on a surface to simulate germs. Once a room is cleaned, workers use a UV lighter to see if germs have been removed. In terms of technology, iPads can be used as a means to create more flexibility. For example, when a marker is placed, it’s very specific, so the next day, a different auditor can grab the iPad and download all the different markers. This allows a different person to conduct the assessment if someone is sick or busy.
These audits involve a detailed list of what housekeeping staff must do in a room, but also include a supervisor working one-on-one with the housekeeper in an unoccupied patient room. Together they scroll through a list, and the supervisor observes everything the cleaner is doing, including proper hand hygiene.
“Ideally the supervisor would be using the checklist on an iPad so that this could be documented,” said Waisman. “But we also want to get to a place where we are marrying corporate coaching skills with what a supervisor does. At the end of the day, we’re trying to inspire change and create leaders with our housekeeping team, so this really takes it to the next level.”
These audits can trace a specific molecule in all dead or alive organisms. They involve swabbing a surface and placing the swab in a luminometer to measure the amount of bioburden. It is easy to apply; however, it can only be applied to areas that are visually clean. With the technology, a supervisor must select from the many luminometers and swabs on the market, and many brands provide various readings. Waisman suggested that managers select swabs that are resistant to chemicals, and once they choose swabs and luminometers, they should stick with that one manufacturer in order to create their own thresholds.
“It might be through the roof at first, but then as you start to document this information and assess the cleaning program, you’ll start to bring scores down and have one threshold,” he noted.