Healthcare in America is still perceived as inefficient, of varying quality and expensive, with the per capita spend on healthcare the highest in the world. Preventable errors, and the failure to detect or prevent them, further contribute to gaps in the quality of care provided. Hospital cleanliness, including cleaning medical equipment carts, can have a positive impact on the quality of care.

Quality of Care

Quality is simply defined as efficiency and effectiveness – and America is leading the way for changing the dynamics of the basis of competition in the industry to reflect quality performance.

This will allow healthcare consumers to make choices based on:

  • Overall quality
  • Costs
  • Clinical outcomes

Currently, most choices are based on patient perceptions and provider referrals – while patient perceptions are important – they do notice the cleanliness of their facility – it does not reflect real ‘clinical outcomes.’ Most hospitals will publish patient satisfaction surveys (such as HCAHPS scores), very few publish their clinical outcomes, it is more common for providers that do well to publish theirs to generate referrals.

Most big healthcare systems will drive referrals to inhouse providers and facilities. You may wonder why this is important? The industry is overwhelmed by measurements, but they are often not comparable and remain in the silo formats so favored by industry, thus creating a disconnect between infection control, the quality drive, and patient safety.

A true quality orientation starts with a solid foundation – providing a safe environment, yet cost-effectively managed. It reflects a level of compassion and vigilance for patient welfare that is as important as any other aspect of competent health care.

Environmental services (hospital cleaning services) and cleanliness is often the neglected child on the block, but it forms the foundation of the quality of care building blocks. Others include:

  • A strong visionary leadership team
  • A quality and safety culture
  • A patient-centric approach
  • The responsibility lies with each staff member
  • Interdepartmental co-operation and coordination of efforts
  • Professional and adequately trained staff
  • Ongoing training programs
  • Technology to enable appropriate measurement
  • Benchmarking
  • Appropriate programs to follow up on feedback and ensure continuous performance improvements
  • Staff satisfaction (to reduce turnover)

Healthcare Associated Infections (HAI’s)

Healthcare Associated Infections occur as a result of healthcare interventions in any healthcare setting. Healthcare Associated Infections (HAI’s) can create major complications downstream, and like all preventable adverse healthcare events create harm to the patient, but also major financial consequences for the patient, family, provider, and insurance.

Healthcare Associated infections (HAI’s) affects as many as 1 in 25 people and is by far the most common complication among people receiving hospital care.

It is estimated that:

  • 2 million patients suffer with HAI’s annually in the US
  • Nearly 90,000 are estimated to die
  • The overall direct cost of HAI’s to hospitals ranges from $28 billion to $45 billion
  • The excess length of stay for postoperative sepsis is 11 days, at a cost of almost $60,000 per patient, according to AHRQ indicators (Agency for Healthcare Research and Quality)

Insurers seldom pay for adverse events, and even when they do, it is often far below the actual cost. Hospitals end up carrying that treatment cost; but, as with any business, cost-effectiveness is of paramount importance to realize the company’s growth potential.

Factors that increase the risk of HAI’s include:

  • Infrastructure repairs (airborne fungal diseases)
  • Immunocompromised patients
  • Greater age and acuity of patients
  • Complex treatments (especially outside of hospitals)
  • Overcrowding
  • Understaffing
  • Rapid turnover of patients
  • Increased antimicrobial use creating resistant microbial strains

Why is the HCAHPS Survey important?

CMS (Centres for Medicare and Medicaid Services) requires the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, measuring patient satisfaction, for all hospitals in the United States. MGH administers the survey to patients by phone shortly after discharge and includes all adult patients (excluding psychiatric patients).

A patient’s perception of hospital cleanliness is highly correlated with multiple safety, quality, and experience measures (see graph below).

Graph from Environmental Services: Delivering on the Patient-Centred Promise. Press Ganey

The survey is used for:

  • Patient’s perception of care provided
  • The government reimburses on the results
  • Published on the internet and affects the facility’s reputation

Infection Control

The evidence is mounting that environmental contamination plays an important role in the acquisition of organisms and the development of HAIs.

Care environments are fraught with bacteria and other microbes; also, the rate of multidrug-resistant organisms continues to rise and cause infections that are becoming increasingly more difficult to treat. This includes MDR organisms such as Clostridium difficile and Norovirus, where environmental sources have been linked to multiple outbreaks. An abundance of opportunity in the care environment for contamination with the patient’s bacteria, and proper cleaning is of extreme importance as approximately 20% of HAI’s are due to the environment surrounding the patient – and what is used more than the medical cart?

This makes a patient with a compromised immune system extremely vulnerable.

If a hospital or other healthcare facility focuses on trying to make healthcare more efficient, without checking clinical outcomes, they may soon regret it. Trish M. Perl, MD, MSc, professor at Johns Hopkins University School of Medicine and in the department of epidemiology at the Bloomberg School of Hygiene at Johns Hopkins, told Infectious Disease News: “Not everything is preventable, but is it worth it to invest the time and money to make sure rooms are clear of these organisms? Absolutely.”

Prevention of infections in hospitals include:

  • Standards – defining best practices that are evidence-based is critical, and education and training in best practices must be done regularly. There is no gold standard defined, and it varies a lot between hospitals.
  • Disinfectants – the caustic nature of disinfectants and environmental concerns, as well as the fact that bacteria are becoming resistant to many of them are complicated issues and needs to be addressed by the quality teams in conjunction with the infection control department and environmental services.
  • Monitoring cleanliness – there is a disconnect between the required standard of cleaning and actual cleaning, mostly due to a lack of methods to monitor how well rooms and equipment pieces are cleaned.
  • Importance of cleaning staff – they are often low-paid individuals with high turnover and little understanding of the importance of their role.
  • New technologies – for disinfection methods (e.g., hydrogen peroxide vapor, ultraviolet light, ATP, etc) to be used as adjuncts to standard cleaning. Robots are becoming popular in performing final sterilization tasks in hard to clean pieces of hospital equipment and rooms.

Methods include:

  • Cleaning – removal of visible organic and inorganic material from objects or surfaces. This is done manually or mechanically with water and detergents or enzymatic products and is always done before using disinfection or sterilization techniques. Decontamination is done to remove pathogenic microorganisms from the surface to make them safe to handle.

Antiseptics are germicides used on skin or other living tissue; disinfectants are only applied to inanimate objects and are antimicrobial in nature.

  • Disinfection – removes pathogenic microorganisms except for bacterial spores from inanimate objects. Chemical sterilant will kill spores with prolonged exposure of at least three hours. Depending on the type of disinfectant, concentration, the physical object being cleaned (i.e., crevices, etc), temperature and pH and other factors some disinfectants will kill different types of organisms, spores, fungi or viruses.
  • Sterilization -Sterilization destroys all forms of microbial life by physical or chemical processes, such as dry heat, steam under pressure, EtO gas, liquid chemicals, and hydrogen peroxide gas plasma.

The Spaulding approach to disinfection and sterilization has informed most evidence-based guidelines for infection control for over 30 years. It categorizes items for cleaning as critical, semi-critical and non-critical and types of cleaning, disinfection and sterilization is advised by the CDC.

Environmental Services

Environmental Services is typically outsourced and reports to the facility manager, when, in fact, it is the foundation of the quality improvement process. They may get an update once a month on areas not properly cleaned – already a month too late! A coherent strategy is required to ensure that they are incorporated properly into the quality team and that combined efforts are organized, efficient, measured and valued.

As part of AHRQ’s The Effect of Health Care Working Conditions on the Quality of Care research portfolio (RFA HS-01-005), a team of interdisciplinary scholars developed a model depicting aspects of organizational climate and their relationship to worker and patient outcomes, depicted below.

Environmental Services: Delivering on the Patient-Centred Promise. Press Ganey

Tips for Cleaning Medical Carts

Medical carts are high-touch areas that require regular cleaning to prevent the spread of healthcare associated infections. Tips for keeping medical carts clean are much broader than simply cleaning them and include:

1. Purchase medical carts that are:

  • Easily maintained and repaired.
  • Cleanable with hospital-grade detergents, disinfectants, and cleaners according to the most current standards and guidelines.
  • Electronic equipment should only be considered if they can be cleaned properly.
  • Hot battery packs must be easily swappable to allow for thorough cleaning
  • Approved by all departments involved in the overall quality management process, i.e., clinical care, infection control, safety.
  • Has equipment specific written instructions on the proper cleaning and decontamination of the medical cart.
  • Provide staff training on the cleaning of all new equipment including medical carts.

2. Assess and improve cleaning methods and procedures regularly to ensure a pathogen-free environment and prevent the transmission of bacteria, viruses, and other sources of infection.

3. Perform regular audits that measure the actual cleanliness of high-touch surfaces

4. Promote staff accountability for cleanliness – making cleaning a constant process helps prevent the drying out of contaminated fluids that may make it more difficult to clean at a later stage, or that can congeal in corners and nooks.

5. Encourage self-audit procedures so that medical carts are kept clean and not only done before institutional audits.

6. Practice excellent hand hygiene when using the medical cart and remember that gloves do not negate the need for good hand hygiene. Antimicrobial hand rub can be used when the hands are not visibly soiled as they rapidly kill most transient microbes.

7. Do not leave medical carts in high-traffic areas where people can be tempted to place items on top of it, e.g., urine samples which may be contaminated.

8. Wipe spills or splatters immediately with disinfectant wipes – it is recommended to keep a container of disinfectant wipes on the medical cart for easy access.

9. Keep your medical cart organized – it makes it easier to find critical items and easier to clean systematically.

10. Set policies and procedures for cleaning of medical carts:

  • Incorporate infection control and prevention that help minimize the spread of infection.
  • Must be understandable and attainable.
  • Keep cleaning continuous.
  • Clearly define cleaning frequency and standards.
  • Cleaning schedules ensure no area is missed.
  • Accountability for cleaning must be clearly defined.
  • Ensure all statutory requirements are met, for example, disposal of contaminated items, or clinical waste.
  • Review them as often as possible.
  • Incorporate special precautions for MDR infections such a C difficile.

11. Perform routine hospital-grade cleaning as directed, as well as in between patients.

12. In isolation facilities, follow the procedures and instructions for isolation care and cleaning scrupulously and record the cleaning as such. It may require the use of Personal Protective Equipment such as gowns, gloves, glasses, masks, and the use of stronger disinfectants.

13. During outbreaks, more stringent and frequent cleaning may be required, based on the facility’s policies and procedures.

14. Perform regular monitoring of surfaces for disinfection and cleaning.

15. In some hospitals, germ-zapping robots are employed to perform additional disinfection with ultraviolet light after daily and terminal cleaning and have shown excellent results:

  • 57% reduction in MRSA infection rates.
  • 70% reduction in C difficile infection rates.
  • 100% reduction in total joint SSIs.

Maintaining an environment with a low pathogenic burden is critical for preventing healthcare associated infections. Easy to clean medical carts are the starting point in this journey. Scott-Clark Medical provides a range of medical carts for all purposes, that may be customized, made of extruded aluminum and stainless-steel that has been powder coated for long-lasting, safe use in healthcare settings.

Madilyn holds eight nursing qualifications including General Nursing and Psychology, Midwifery, Pediatrics, Operating Room, Professional Ethics, and Adult Education with many years clinical, teaching and management experience specializing in Clinical Outcomes Research and Quality Improvement. She has a special interest in psychology and neuroplasticity and how we can guide our thoughts to improve attitudes, quality of life, and health outcomes. She works extensively with special needs children in her spare time. She has been writing professionally for over 30 years.
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