The mission of the Pretoria Infection Control Society (PICS) is to promote the exchange of knowledge, information, ideas and support for the prevention and control of hospital and community-associated infections. To effect this, PICS hosts quarterly mini symposiums for Infection Control Practitioners and nursing staff. At the most recent symposium held at the Netcare Regional Training Centre in Pretoria, Marietjie Swanepoel, of MS Consultancy, as a subject matter specialist, presented on the topic of ‘How to measure cleanliness in healthcare facilities’. According to Swanepoel, performing regular cleaning audits in healthcare settings are crucial, and although the link between Hospital Acquired Infections (HAI’s) and cleaning has not been scientifically proven, we know that certain pathogenic organisms that can survive on surfaces for months are vulnerable to the cleaning process.

The measurement of cleanliness is often part of an overall infection control package in response to an outbreak. However, it is recommended that baseline measurements are established, and progress is monitored over time. This way healthcare facilities can track the effectiveness of their cleaning protocols and make data-driven adjustments as needed. The link between infection control and potential sources of contamination is undeniable, making it essential to assess and address the bioburden present on various surfaces. By breaking the chain of infection by applying the correct cleaning practices, healthcare facilities can create a safer environment for patients, staff, and visitors.

So how do you measure cleanliness?

Swanepoel states that a visual inspection is one of the primary means of assessing cleanliness and is an essential component of quality control in a healthcare environment. However, before conducting a visual inspection, it is important to review if the correct standard operating procedures are in place, outlining the cleaning methodologies and cleaning standards.

Once you have established that the standard operating procedures (SOP) adhere to best practices, you need to verify that all the housekeeping staff have been adequately trained, and records of the training should be available. Swanepoel recommends that the training covers cleaning protocols, infection control measures, as well as health and safety measures.

Once you have established that the correct procedures are in place, and staff have been adequately trained, the inspection can commence. Inspection checklists serve as a valuable tool during visual cleaning inspections; each area should have its own checklist.
The areas would include the inspection of the housekeeping department/ storerooms, different risk areas in healthcare facilities, public areas, wards, and high-risk areas such as Intensive Care Units and theatres.

Housekeeping staff should be evaluated, by demonstrating proper cleaning techniques, correct usage of cleaning materials and chemicals, correct dilution of chemicals, and the understanding of and adherence to cleaning schedules. Part of the assessment would include evaluating their hand-washing procedures.
The next step is a physical assessment of the housekeeping staff. Their ability to use the correct cleaning techniques (as per the SOP’s), their ability to select and dilute chemicals and end of task duties must be evaluated.

Surfaces, especially critical control points, are examined for visible contaminants such as dirt, stains, or residue. While visual inspections provide valuable information, they may not detect microbial contamination that is not visible to the naked eye, so how would you measure that?

ATP (Adenosine triphosphate) meters are a valuable tool for measuring cleanliness. These devices detect the presence of ATP, a molecule found in living cells. By swabbing surfaces and analysing the swab with an ATP meter, the level of organic material and potential microbial contamination can be assessed. High ATP readings indicate insufficient cleaning, prompting targeted interventions to improve hygiene practices.

Ultraviolet (UV) lights and stamps are alternative methods used to identify areas that may have been overlooked during cleaning. UV lights can reveal residues that are not visible under regular lighting conditions. Stamps, coated with a fluorescent marker, can be applied to surfaces before cleaning. If the stamp is still visible, after cleaning, it indicates that the surface was not adequately cleaned.

Swabbing surfaces and conducting microbial testing is another approach to measuring cleanliness. Swabs are taken from different areas, and the collected samples are analysed in a laboratory to identify the presence of microbial contamination and can help identify specific areas that require improvement. This method would only be recommended in high-risk areas when there is a potential breakout.

In conclusion, Swanepoel emphasises that measurable outcomes are essential in cleaning audits. These outcomes can include reductions in ATP readings, decreased microbial contamination, or improved visual inspection scores. By establishing baseline measurements and monitoring progress over time, healthcare facilities can track the effectiveness of their cleaning protocols and make data-driven adjustments as needed.