Impact of an Environmental Cleaning Intervention on the Presence of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on Surfaces in Intensive Care Unit Rooms

Environmental contamination with pathogens commonly occurs during routine medical care. Many studies have described transmission of pathogenic organisms through contact with contaminated room surfaces.1–3 Of particular concern is the potential for transmission of multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), which are associated with healthcare-associated infections, increased lengths of stay in hospitals, increased healthcare costs, and increased mortality.4–7 Cleaning is essential to reduce environmental reservoirs of known hospital-acquired pathogens. Surfaces in rooms occupied by MRSA-positive or VRE-positive patients can contaminate the hands of healthcare workers who touch these surfaces without touching the colonized or infected patient.8–10 Both MRSA and VRE have been isolated from various fomites, including beds, linen hampers, doorknobs, and window ledges.11–16 Studies have demonstrated that these antimicrobial-resistant pathogens can persist on room surfaces even after discharge cleaning.17,18 Interventions that address the thoroughness of room cleaning have proven successful in reducing the environmental burden of such organisms.13 Although the goal of environmental cleaning and disinfection is not sterilization, adequate cleaning requires sufficient removal of pathogens to minimize patients’ risk of acquiring infections from hospital environments. This is particularly true in areas serving high-risk patients, such as intensive care units (ICUs). The Environmental Services department at Brigham and Women’s Hospital has routine cleaning policies that exceed national performance standards.19 Examples of added measures include exchanging bed curtains after discharging patients who were placed under contact precautions and using pour bottles to dispense disinfectant, which results in quantities of applied agent that are larger than those dispensed by spray bottles. In addition, all Environmental Services staff receive hands-on training in cleaning protocols and twice-monthly quality-control assessments that affect compensation. Nevertheless, we have recently shown that patients admitted to ICU rooms previously occupied by MRSA or VRE carriers are at increased risk for MRSA or VRE acquisition.18 It is possible that high-risk areas occupied by patients who are critically ill, often with wounds, medical devices, and immunocompromised states, have need of more-intensive cleaning protocols to reduce transmission of and subsequent infection due to these and other pathogens. Recently, a novel and nontoxic tracking marker that is visible only under a UV lamp (“black light”) has been developed to assess the quality of environmental cleaning. It is invisible and can be removed only with sufficient moisture.20–23 Feedback based on this evaluation system has been shown to improve cleaning technique, but it is not known whether it produces reductions in environmental contamination. We assessed whether an intervention involving improved cleaning practices, staff education, and feedback based on the black-light monitoring system would impact the thoroughness of discharge room cleaning and the environmental prevalence of MRSA and VRE in ICU rooms.