GREENING OF HOSPITALS WORKSHOP

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

Paradigm Shift #1 Using Flat (Microfiber) Mopping Systems in Hospitals

Take Home Message Practical, common-sense approach for patient care areas, but WILL NOT meet all mopping needs. Immediate water and chemical savings, but most cost savings are a result of reduced labor. Improved ergonomics and cross-contamination infection control 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? 1/100th of human hair Split wedged shape of Polyester fiber

…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

Place 2. Mop 3. Peel 4. Launder Flat Mopping Systems: How Do They Work?

vs. Conventional Loop Mops Dip and Wring Mop Repeat 3x Change Water 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 “Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

Microfiber Considerations • Cannot be used in areas contaminated with blood or body fluid • Some products ineffective in greasy, high traffic kitchen areas • Sticky floors? Non-industrial washing machines must be used to wash microfiber mop heads

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

Microfiber Mops 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 Cost Analysis: Lifetime Mop Costs

Microfiber Mops Conventional Wet Loop Mops • 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 • 22 rooms cleaned per day • $0.50 in chemicals per 100 rooms Cost Analysis: Chemical Costs

Microfiber Mops Conventional Wet Loop Mops • 21 gallons per day • 20 rooms cleaned per day • 105 gallons of water used per 100 rooms • 1 gallon per day • 22 rooms cleaned per day • 5 gallons of water used per 100 rooms Cost Analysis: Water Use

Microfiber Mops Conventional Wet Loop Mops • 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 Cost Analysis: Labor Costs

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 Who’s currently using microfiber mops? How satisfied are you with them in patient care areas? What hurdles did you have to overcome? What have you seen as the greatest benefit to using microfiber mops?

Take Home Message Practical, common-sense approach for patient care areas, but WILL NOT meet all mopping needs. Immediate water and chemical savings, but most cost savings are a result of reduced labor. Improved ergonomics and cross-contamination infection control Proactively address potential hurdles to implementation.

Resources EPA Factsheet http://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

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 Carling’s 14 High Risk Objects

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

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

Future Patient Rooms

GREENING OF HOSPITALS WORKSHOP