How a 'pit crew mentality' can improve a healthcare facility's terminal cleaning policy

While infection control practices have contributed to declines in healthcare associated infections, the morbidity and mortality associated with these conditions remains significant. The bacteria Clostridium difficile (C. diff) is one of the most common healthcare associated infections (HAIs). Each year in the U.S. the pathogen causes more than 223,000 infections, contributing to approximately 12,800 deaths, according to the U.S. Centers for Disease Control (CDC).

Treating infections like C. diff also places a considerable financial burden on the healthcare system. One 2018 study published in the journal Clinical Infectious Diseases estimated the cost of treating C. diff to be $24,205 per patient.

Leaders of healthcare organizations are tasked with protecting their patients and their bottom lines from HAIs. To achieve this, interdisciplinary teams must be assembled to enact a terminal cleaning policy. These policies require cleaning processes to occur every 24 hours. These processes should include cleaning the entirety of a healthcare facility, including walls, floors and all equipment. Gabrielle Cox, RN, MSN, Director of Education and Training for STERIS Instrument Processing Solutions said that in the past, healthcare facilities have focused mainly on cleaning operating rooms.

"Less time and attention is spent on places like sterile processing and the rooms where patients come in and wait before they go back to surgery," she said. "We haven't treated those spaces in the manner that they deserve."

Lack of adequate and thorough cleaning in healthcare facilities can contribute to the proliferation of HAIs like C. diff. Research published by the Lancet pointed out that only 50 percent of surfaces in hospital rooms are sufficiently cleaned between uses. As a result, patients who then occupy rooms used by patients infected with multidrug resistant organisms are at an increased risk of infection. Additionally, when staff come across surfaces that haven't been properly cleaned, they can spread the infection to others. Creating and using a terminal cleaning policy can help decrease the spread of multidrug resistant organisms. "Terminal cleaning is the responsibility of everybody in the facility," Ms. Cox said.

A terminal cleaning policy is more than just scrubbing floors, taking out trash or straightening a patient's bed table. A successful policy includes having all staff on the same page, with each staff member assigned their own task to complete. There should also be dedicated teams tasked with cleaning both the operating rooms and perioperative areas. The Association of periOperative Registered Nurses describes1 this approach as having a "pit crew mentality," where each member of staff is laser-focused on their specific task to ensure nothing is overlooked.

This approach leads to a more efficient and thorough terminal cleaning process. Ms. Cox recommends taking the "5S" approach when developing a terminal cleaning policy. "The five steps include sorting, set to order, standardizing, shine, and sustaining," she said. "The policy should include cleaning the entire area instead of focusing on certain areas or pieces of equipment."

The 5S's of terminal cleaning

The first step to creating an effective terminal cleaning policy includes keeping areas tidy and sorted before cleaning takes place to ensure staff don't feel overwhelmed by the mess. Setting to order requires every cleaning item to be in the same place so everyone can easily access and use them.

Facilities should then standardize products and supplies that can be used by each member of the team when cleaning their respective areas. That way, when staff moves from room to room, they don't have to waste time stopping and reading labels on chemicals they're trained to use.

Standardizing involves evaluating staff performance to ensure everyone is following through with their assigned tasks and taking a consistent approach. Maintaining consistency can be difficult in the operating room when cleaning can be rushed along by surgical staff. "It's really important to have a champion surgeon who understands the terminal cleaning workload so they're not setting the expectation of hurrying through the process," Ms. Cox said. "Consider searching for a champion surgeon within the organization to get everyone on board with the policy."

The next step — shine — involves developing a maintenance schedule for the facility where each member assigned to a room knows their role in maintaining it and shares status updates about it with other staff to ensure there's no overlap in cleaning schedules between rooms.

Lastly, leadership should make their terminal cleaning policy sustainable by fostering a mindset among staff that it is everybody's job to ensure the facility is cleaned properly. This also involves regular staff training to keep everyone up to date on terminal cleaning policy. Staff should also understand that cleaning chemicals are not created equal — each chemical is designed to be used in a certain way with a set dwell time to inactivate different microorganisms. Dwell time — or the amount of time it takes for a chemical to take effect — is a key part of executing a terminal cleaning policy. "If it says five minutes on the bottle and you wipe a surface down three minutes after, then you've done nothing," Ms. Cox said. "Staff should know exactly how a chemical works. Always follow the manufacturer's instructions for use."

When cleaning chemicals aren't used properly, staff wastes both their time and the chemical as a result. In addition to dwell time, some chemicals must reach a certain temperature level to be effective. "If you're using something outside of its scope, it's as if you did nothing at all," Ms. Cox said. Timing is important when sterilizing instruments as well — proper timing ensures that instruments are sterilized effectively. Staff should pay attention to both bioburden — the material left behind after a surgery such as blood clots and paper waste —- and biofilm, the substance that "hides" contaminants that fosters bacteria growth. Before taking instruments to the sterile processing department, staff should eliminate as much bioburden as possible. "The time frame really counts when taking instruments from the operating room to decontamination — staff should adopt a 'first in, first out' mentality when putting instruments through the washer to ensure proper sterilization."

Additionally, if a facility uses a group purchasing organization to buy its cleaning chemicals, it's important to keep staff apprised of the specific chemicals the organization purchases.

Because these organizations operate on contracts, they may change out cleaning chemicals without all the proper staff being at the table to choose them. If a facility's group purchasing organization orders new chemicals, staff need to dedicate time to determine the product's instructions for use.

If use instructions have changed, facility leadership should update staff on the new procedures.

The importance of leadership in staff education and training

Similar to other aspects of healthcare, staff education and training for terminal cleaning policies works best when a facility adopts an interdisciplinary team approach. This means involving all stakeholders within a healthcare facility in terminal cleaning policies, including infection control, operating room and environmental services staff. When it comes to the role of leadership in education and training, leading by example is one way to get staff on board. "If staff sees how important terminal cleaning is to you, then it will become important to them," Ms. Cox said.

Staff training and education on terminal cleaning policies should be prioritized. Leadership can stress the importance of a terminal cleaning policy by being involved in staff meetings, setting the bar for staff performance. Leadership should also strive to keep training consistent for new hires. Often when new staff members are brought into a facility, there is a mindset they will pick up on cleaning policies and procedures without much guidance from leadership. However, leaders should make it a priority to ensure new hires are well trained on the facility's terminal cleaning policy.

"Lack of consistency is what organizations often get wrong about terminal cleaning policies," Ms. Cox said. "It goes back to making sure that as new people are brought on, they are trained on policies instead of just having the expectation that they'll simply get it. Training and education should be a topic

of discussion at staff meetings as well."

How to hold staff accountable for inspections

Ms. Cox recommended adopting an internal auditing system to ensure staff is ready for cleaning inspections. This system works by assigning anonymous staff members to watch over areas and check if policies are being followed. In this situation, staff can also adopt AORN's pit crew mentality, with each staff member responsible for a specific aspect of the policy. Directly involving staff in inspections and assessments can empower these specific team members to follow the policies themselves. Making a point to praise staff when they do a good job can encourage staff further.

"Praise can do wonders for staff," Ms. Cox said. "Thanking them for going above and beyond can help with performance in assessments and inspections."

If leadership shows they're willing to be accountable for the cleanliness of the facility, it can help encourage staff to do the same. For example, if leadership offers to help clean one to two rooms a day, it can help stress how important the facility's cleanliness is to them.

Inspections and terminal cleaning are tasks that shouldn't rest on a single staff member's shoulders — it should be a priority for all stakeholders in a healthcare facility. "Terminal cleaning is everybody's job no matter what," Ms. Cox said. "Everybody is capable of mopping the floor.

All staff should have an active role in maintaining the cleanliness of the facility."

This article is sponsored by Steris IMS.

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