It May be Disinfected, but, Is It Clean?

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Hospitals are a hotspot for acquiring dangerous and life-threatening infections, which are transferred patient to patient when sufficient prevention measures are not in place. Cleaning hospital surfaces is abstract without a verifiable and quantifiable method for detecting just how clean a surface is. We can exploit certain essential properties of bacteria and fungus to aid in their detection so that we can ensure patients and visitors are not infected by preventable diseases.

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It is a time worn tradition to use a white glove to inspect surfaces for cleanliness. For too long now, “clean” has been a subjective term. Two people inspecting the same room or the same object might have a different opinion about whether or not it passes the “white glove inspection”. If we state a room is “clean”, we infer that it is also safe for patients or other occupants. But, is it really clean?

Infection prevention is enhanced through environmental hygiene because a clean surface will not support the growth of microorganisms. The question now is how do we know if a surface is actually clean?

We also established that surfaces appearing to be clean might not necessarily be clean when scientifically quantified or qualified. Remember, what you can’t see, can hurt you. We should be striving for health-based or hygienic cleaning (i.e., cleaning for health and not just for appearances).

We need evidence.

We need validation.

A well-trained staff, given adequate time, equipped with the best tools, chemicals and processes will deliver a clean, sanitized room. But, we need to validate that the training, tools, chemicals and processes are producing the desired end product. We need evidence. We need validation.

Tom Peters said, “That which gets measured gets done.” We need to be intentional about measuring the important things, those touch-points that, more often than not, are not clean to a standard. Recent hospital studies have found that only 25%-45% of touch-points nearest to the patient met the definition of “clean”. When measurements and interventions were employed, the rate of “clean” went to 75%. Although 100% wasn’t attained, the touch-point presented 50%-75% less risk of cross-contamination.

More and more people are augmenting or enhancing the “white glove” with rapid testing technologies along with interventions (i.e., sharing testing data with, educating and training the cleaning staff). Those technologies move us from, “I believe it is clean,” to “I have proof it is clean.”

Until cleaning becomes an evidence-based science, with established methods of assessment, the importance of a clean environment is likely to remain “any one’s guess.”

Integrated Cleaning and Measurement (TM) (ICMTM) is an approach to cleaning that incorporates measurement as one of the keys to process improvement. Cleaning professionals want to be able to organize and equip staff to focus on results and then prove that what they are doing is effective.

At its core, ICM is a four-step model: measure, compare, experiment, and implement. ICM is an open-source system and is not restricted by a single method or product. Rather, the system accepts best-practice equipment and approaches, provided they are accompanied by measurement data confirming their effectiveness to other methods.

Those interested in evidence-based, objective measurement of surface hygiene are using various methods. Some are using chemical markers (either dry or wet) that are invisible to the naked eye but show up with ultraviolet light. These markers are easily removed with normal cleaning. The transparent markers are placed on touch points before the cleaning is performed and then checked with a UV light to validate that adequate removal has been done.

Others seeking evidence are using hand held meters that test surfaces for adenosine triphosphate (ATP)-the energy molecule inside all living cells. ATP is found in bacteria, mold and fungus, as well as other matter that can provide a rich food source for these dangerous pathogens.

ATP measurement has been used in food processing for years, but until now, the cleaning industry lacked such precise and portable devices. By providing feedback in less than 30 seconds, ATP meters enable custodians and cleaning professionals to verify how clean surfaces are, and carry out continuous improvement programs to enhance overall performance.

Other measures of “clean” include: fungal enzyme, RODAC plate, petri film, particle counter, airborne dust mass, infrared/moisture detection, and other device and measurement platforms are becoming increasingly available, portable, and affordable.

You need to be able to back your “clean” claims with scientific measurement, or, get out the checkbook.

What is the cost of not providing a safe, clean environment? It could be millions of dollars. A court awarded $13.5 million to the family of a patient who died of flesh-eating bacteria that she contracted during chemotherapy treatment in a facility. In a separate case, a patient was awarded $2.58 million because he contracted MRSA in a hospital. The courtroom is no place to discover that your cleaning methods are woefully lacking. You need to be able to back your “clean” claims with scientific measurement, or, get out the checkbook.

In conclusion, simple cleaning of the environmental surfaces may be our only defense in the future. With antibiotic-resistant organisms proliferating on common touch-points for up to 56+ days, the study of cleaning and measuring cleanliness is becoming all-important.

The time has come to get rid of “housekeepers” in favor of “hygiene specialists” who are given the high recognition deserving of their role. The hygiene specialist must be well trained, given sufficient time to do the necessary tasks, given the test data gathered by scientific measurement, educated about the transmission of disease, and given the necessary tools and equipment. Infection prevention will become a reality when the hygiene specialist has partners to maintain the cleaned environment on an on-going basis.

Then and only then will we be able to say with assurance, “The room is CLEAN and SAFE!”


  1. The points that Darrel makes here represent just one side of the coin. There is a need to “Re-Define Cleaning” and there are two core components to this:

    1: Measurement, which Darrel discusses here because as Peter Drucker noted: “If you can’t measure it, you can’t manage it”! And when it comes to Infection Control our focus is primarily on “Managing The Environment” with a view to “Prevention”.

    2: Clear Objective(s), which requires an appreciation of the issue that is in need of being resolved; what are we wanting to remove

    It is this 2nd point that I feel needs more focus, because what is the point of Measurement if one is not clear on:

    (a) what are me measuring, and why?
    (b) this will in turn determine how we measure

    With regard to (a) the reason ATP is used by the USDA is that the lower the ATP levels, the lower the probability of there being a pathogen biofilm present on the surface.

    Biofilm is the critical issue here, and for the following reasons:

    (i) The CDC and NIH have noted that biofilms can make pathogens between 500 Xs to 1,000 Xs more resistant against disinfectants and sanitizers because it prevents such agents reaching and penetrating the pathogen cell wall.

    (ii) The CDC and NIH have also noted that viruses can reside in a biofilm in the absence of a host. (This is especially important given the recent research on MERS where it was noted that the virus survived on surfaces much longer than previously believed. One of the core contributing reasons for this is the presence on biofilm on surfaces.)

    (iii) Most disinfectants and sanitizers do not remove biofilm. They will damage biofilm, most often weakening the top layers of the biofilm and kill some of the pathogen in those top layers but they rarely remove them. Furthermore, in the wiping process by which most sanitizers and disinfectants are applied, the dead pathogens are merely smeared around the surface, and so provide protein for the surviving pathogens to live of. (Don’t forget the problem of Quat Binding)

    What is not appreciated is that pathogen biofilms can replicate as rapidly as every 20 minutes.

    This is why it is crucial to address the presence of biofilm. And this also impacts how we measure the level of clean.

    All too often the standard protocol is to conduct an ATP test before cleaning, and then immediately after. This protocol only tells “half the story”. Any cleaner, sanitizer and / or disinfectant will lower ATP levels immediately after cleaning. If they didn’t they shouldn’t be on the market.

    The real issue is that given a pathogen biofilm can replicate as rapidly as every 20 minutes is how long will those post cleaning ATP levels remain low? If the biofilm is not properly addressed then within just 2 to 4 hours the ATP levels are rapidly heading back to levels nearing those noted before cleaning!

    The implications of this are huge. A school desk cleaned in the evening may have immediate post cleaning ATP levels that are much lower than before cleaning, BUT by the time the students are back in the class room the next day those ATP levels are likely to be back to near their pre-cleaning levels. The same with offices, hotel rooms (especially if the room was vacant a day or two, which is likely given average ocupancy rates of 80%), and of course healthcare facilities.

    So we need to understand what the objective of cleaning is (addressing biofilm) and have appropriate measuring protocols that give us a genuine understanding as to not only how clean a surface is immediately after cleaning, but how long that clean lasts (which is a means of determining how effective the cleaning products and protocols really are at addressing biofilm).