Manual cleaning is the recommended method of environmental disinfection and plays a key role in the prevention of healthcare-associated infections.Reference Han, Sullivan, Leas, Pegues, Kaczmarek and Umscheid1 Recently, automated “no-touch” disinfection technologies such as ultraviolet (UV) light have been proposed to supplement manual cleaning.Reference Anderson, Moehring and Weber2,Reference Anderson, Chen and Weber3 In our institution, we implemented UV light for terminal disinfection of contact precautions rooms at discharge. However, we hypothesized that UV light may affect quality of manual cleaning by possibly leading to complacency because housekeepers may feel that it replaces the need for thorough manual cleaning. Furthermore, UV light adds time to the overall cleaning process. We evaluated the impact of adding UV light on the quality of manual cleaning and on room turnaround times.
Methods
The University of Iowa Hospitals & Clinics is an 811-bed academic medical center. According to hospital policy, contact precautions rooms undergo manual cleaning with bleach and UV light using continuous UVC waves (Tru-D SmartVUC, PDI Healthcare, Woodcliff Lake, NJ). UV light time is determined automatically based on room size.Reference Nerandzic, Cadnum, Pultz and Donskey4 Rooms without contact precautions are cleaned using quaternary ammonium only (no UV light). During January–September 2019, we obtained a convenience sample of rooms cleaned at discharge (24 UV-light rooms; 201 non–UV-light rooms). Each room was assigned a thoroughness of disinfection cleaning (TDC) score of environmental surfaces.Reference Guh and Carling5 The rooms were identified for TDC assessment after patient admission and were selected randomly by an infection preventionist. Housekeepers were not informed of which rooms were selected. Fluorescent markers, which are not affected by UV light, were applied on high-touch surfaces once discharge orders were placed, and thoroughness was assessed at the completion of terminal cleaning. TDC scores were defined as the percentage of cleaned surfaces out of the total examined surfaces. This information was shared with staff.
We compared TDC scores between UV-light rooms and non–UV-light rooms. We also calculated the manual cleaning time, UV-light cycle durations, and total turnaround time for rooms undergoing terminal disinfection (2,178 UV light rooms and 50,877 non–UV-light rooms). Room turnaround time included time for bed making, room preparation before and after the UV-light procedure, and UV light set-up and dismount, where applicable. No preoccupancy recovery time was needed.
Results
We assessed 2,383 surfaces in 24 rooms with UV-light disinfection and 201 rooms without UV-light disinfection. The TDC scores were similar in rooms with UV-light disinfection (243 of 273 surfaces) and rooms without UV-light disinfection (1,835 of 2,110 surfaces; 89% vs 87%) (Table 1). The housekeepers’ median manual cleaning time for the UV-light–treated rooms was 56 minutes (interquartile range [IQR], 37–79 minutes) versus 33 minutes (IQR, 22–43 minutes) for untreated rooms. The median turnaround time for UV-light–treated rooms was 156 minutes (IQR, 87–216 minutes), of which a median time of 49 minutes (IQR, 35–67 minutes) was used for the UV-light procedure. In untreated rooms, the median turnaround time was 58 minutes (IQR, 40–86 minutes).
Table 1. Impact of Ultraviolet Light Treatment on TDC Scores and Cleaning Times, University of Iowa Hospitals and Clinics, January–September 2019
Note. TDC, thoroughness of disinfection cleaning, UV, ultraviolet, IQR, interquartile range.
a Noncontact precautions rooms included standard precautions rooms, droplet, and airborne precautions rooms.
b Room turnaround time includes time from when room is assigned for cleaning until time when room is handed back to nursing for use. This was calculated using all rooms terminally cleaned.
Includes time from the determination that terminal cleaning is needed until housekeeper arrives, room stripping, and set-up of equipment for optimal UV-light exposure (eg, moving tables, call box, telephone in direct line of exposure to UV light), waiting for available UV light device, and remaking room after UV light disinfection, if applicable.
Discussion
In our study, we detected no difference in the quality of manual cleaning between UV-light rooms and non–UV-light rooms. Adding UV light following manual cleaning increased the overall room turnaround time substantially.
We detected no difference in TDC scores between rooms cleaned manually followed by UV light versus those cleaned using a manual process only. TDC scores were nearly 90% in both groups. Currently, data comparing the quality of rooms cleaned with added automated disinfection against manual cleaning alone are scarce. A prospective multicenter study evaluating the quality of cleaning found an average TDC score of ~49%.Reference Carling, Parry and Von Beheren6 We believe this difference in our reported TDC versus previous reports may be because of our ongoing audit process. Carling et alReference Carling, Briggs, Perkins and Highlander7 reported that active monitoring of cleaning complemented with education and feedback increases TDC scores. Sustained efforts to educate staff on the importance of manual cleaning are key to avoiding healthcare-associated infections by reducing environmental microbial contamination regardless of the addition of automated disinfection technologies.
Additionally, our study showed that UV light use added 49–75 minutes excess time to the overall room turnaround process. UV-light cycle time contributed 49 minutes to the room turnaround time. We could not fully quantify what proportion of the 26 minutes excess time were related solely to UV logistics: mounting and dismounting of UV lights, mobilizing furniture for UV light, etc. More time was spent manually cleaning rooms considered “dirtier” (ie, 56 minutes vs 33 minutes). Data on the impact of adding UV-light disinfection to the cleaning process on total room turnaround time are limited. The implications of UV-light disinfection with this extra time might worsen patient flow between units or impact emergency department crowding. Therefore, prospective studies to determine optimal time of disinfection with UV light are needed to shorten room turnaround times.
Our study has several limitations. First, we evaluated TDC scores using fluorescent markers, and we did not perform a microbiological analysis (ie, bacterial culture of surfaces). Second, we did not investigate incidence of healthcare-associated infections between rooms with UV light and without UV light.
In conclusion, UV light did not have a negative impact on the quality of manual cleaning but increased room turnaround time. As a result, we reserved UV light use to high-risk units only. The housekeeper’s role is fundamental because of their influence on the effectiveness of cleaning and disinfection. Focus on staff education and an objective assessment of cleaning may be key in ensuring low infection transmission risk and reduced room turnaround times.
Acknowledgments
The authors thank the University of Iowa Hospitals & Clinics Environmental Services staff and the Infection Prevention team for their support during this project.
Financial support
No financial support was provided relevant to this article.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
