Introduction: Distinct protocols can be used to clean the hospital environment. Methods: This study evaluated cleaning protocols composed of either a quaternary ammonium compound plus biguanide (QACB) or bleach only using the ATP too. Results: No statistical difference was found (P=0.450) between QACB and bleach protocols, both being effective in hospital wards cleaning. Conclusions: either the use of QACB or bleach protocols ensure appropriate cleaning in health care, promoting a safe environment for patient use

Caroline Deutschendorf

Cristofer Farias da Silva

Paola  Cristini Gama Silva

Thiago Costa Lisboa

Clinical & Biomedical Research

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Brief Communicationhttps://doi.org/10.22491/2357-9730.129414ISSN 2357-9730http://seer.ufrgs.br/hcpa 209EVALUATION OF TERMINAL CLEANING USING ATP METHODOLOGY: COMPARISON OF BLEACH AND QUATERNARY AMMONIUM COMPOUND PLUS BIGUANIDEPaola Cristini Gama Silva1,2,3      , Caroline Deutschendorf3 ,  Thiago Costa Lisboa3,4,5,6  , Cristófer Farias da Silva1,3,4 AbstractDistinct protocols can be used to clean the hospital environment. This study used the ATP tool to evaluate cleaning protocols composed of either a quaternary ammonium compound plus biguanide (QACB) or bleach only. No statistical difference was found (p = 0.450) between QACB and bleach protocols, both being effective in hospital ward cleaning. So, it is possible to conclude that the use of QACB or bleach protocols ensures appropriate cleaning in health care, promoting a safe environment for patient use.Keywords: ATP; Environmental cleaning; Environmental cleanliness assessment; Hospital environment; Room decontaminationINTRODUCTIONEnvironment cleaning is a relevant process for infection prevention in health institutions. Cleaning is defined as the removal of visible soil by the mechanical action of water and/or detergents1,2, which may be followed by a disinfectant product to reduce the risk of environmental contamination.Currently, many products with different use processes are found in health institutions. Quaternary ammonium compounds (QAC) and sodium hypochlorite (bleach) solutions are frequently used in the hospital cleaning process3. QAC has cleaning and disinfection properties, completing the cleaning process in one step, but bleach has only disinfection properties, which brings a necessity of a cleaning step before bleach use. Differences in cleaning protocols, mainly in products and techniques, may affect the quality of environmental cleaning, which must be measured using quality control tools such as adenosine triphosphate (ATP) bioluminescence devices4. ATP is the primary energy source for enzymatic reactions in living beings, including the bioluminescence reaction mediated by the luciferase enzyme, which provides light, measured in Relative Light Units (RLU) directly proportional to the amount of ATP used5.Since there is a possibility of different results due to different cleaning protocols, the goal of this study was to compare quaternary ammonium compound plus biguanide (QACB) versus bleach protocols for environmental cleaning of hospital wards, using the ATP tool.METHODSWe designed a retrospective study, comparing two protocols for hospital environment cleaning in a tertiary university hospital in southern Brazil. For the aims of this study, terminal cleaning consists of the complete cleaning of the patient’s environment after the patient’s discharge. Wards cleaning routine is performed using one of the following established protocols: 1) one-step protocol, which adopts only QACB 0.5%; or 2) two steps protocol using multipurpose detergent, followed by rinsing, drying, and disinfection with hypochlorite solution 0.1% (bleach). Clin Biomed Res. 2023;43(2):209-2121 Programa de Residência em Controle de Infecção Hospitalar, Residência Integrada Multiprofissional em Saúde, Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brasil.2 Serviço de Farmácia, Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brasil.3 Comissão de Controle de Infecção Hospitalar, Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brasil.4 Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil.5 Departamento de Medicina Intensiva, Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brasil.6 Instituto de Pesquisa HCOR. São Paulo, SP, Brasil.Corresponding author:Cristófer Farias da Silvafar.cristofer@gmail.comHospital de Clínicas de Porto AlegreRua Ramiro Barcelos, 235090035-903, Porto Alegre, RS, Brasil.Silva et al.http://seer.ufrgs.br/hcpaClin Biomed Res 2023;43(2)210The protocol’s choice is determined by an institutional algorithm based on local epidemiology – hospital beds that patients had Clostridioides difficile identified undergo terminal cleaning with the bleach protocol, and the others were cleaned with QACB protocol. Both processes were evaluated by visual inspection and the ATP tool on high-touch surfaces. Terminal cleaning and evaluation are performed by different teams, and ATP measurement is done by random surface sampling, without prior notice to the cleaning staff. For this study, data were collected by convenience sampling from a routine database for terminal cleaning quality control, carried out between January 2019 and December 2021. Data were excluded if they: i) included bathroom cleaning, ii) presented RLU values > 1000, or iii) were incomplete. All surfaces that met the inclusion criteria were included in the statistical analysis. The surfaces were categorized according to the original classification of the institution’s cleaning service. The cleaning process was considered approved if RLU values were ≤ 100 and this categorical data was used for cleaning approval rate analysis. To compare the outcomes by RLU between bleach and QACB, the samples were paired according to surface type, hospital unit, and operator. Descriptive and analytical statistics were performed using the PSAW Statistics Version 18® software. We performed the Mann-Whitney U-test for independent samples and Pearson’s Chi-Square test for median RLU values comparison, at a two-sided significance level of 0.05. Test power was calculated afterward, using the PSS Health tool, available online6.RESULTSDuring the period of the study, 331 registers of terminal cleaning met the inclusion criteria and were included in the data analysis (bleach N = 166; QACB N = 165). We found a cleaning process approval rate of 82.5% for bleach and 86.1% for QACB, with no significant difference (p = 0.450) (Table 1), and test power of 11.4% for the sample number obtained. In the RLU median ATP values analysis, the assay was 29.5 for bleach and 25.0 for QACB, ranging from 1-790 and 1- 454, respectively, without statistical difference in the comparison among sanitizers (p = 0.111) (Figure 1). We normalized data by the natural logarithm transformation. We performed a parametric analysis, and there was no significant difference in results, which reinforces data confidence. The biggest median value for RLU (49) was found in bed rails disinfected with bleach, as done per surface analysis. On other hand, the lowest median value of RLU (15) was found in headboards, also disinfected with bleach.Table 1: The approval rate of hospital ward cleaning using distinct processes.Rate of approval (%)Surface Bleach QACB* pTotal 82.5 (N = 166) 86.1 (N = 165) 0.450Overbed table 84.4 (N = 45) 86.7 (N = 45)Headboard/Footboard 83.9 (N = 31) 83.9 (N = 31)Bed rails 77.3 (N = 22) 87.0 (N = 23)Bed control 90.0 (N = 20) 90.0 (N = 20)Mattress 83.3 (N = 12) 91.7 (N = 12)Bedside table 80.0 (N = 10) 88.9 (N = 9)Others** 76.9 (N = 26) 80.0 (N = 25)*QACB: Quaternary ammonium compound plus biguanide; **Nº of surfaces tested for each disinfectant (bleach/QACB): bed curtain (n = 8/8), cabinet (n = 5/4), armchair (n = 5/5), bedside lamp (n = 3/3), light switch (n = 2/2) alcohol dispenser (n = 2/2), sink (n = 1/1).Evaluation of hospital cleaninghttp://seer.ufrgs.br/hcpa Clin Biomed Res 2023;43(2) 211Figure 1: Comparison of relative light units (RLU) medians between bleach and quaternary ammonium compound plus biguanide (QACB) on the surfaces analyzed in the study.principles is the main contributor to achieving good results such as found in our study.When comparing QACB and bleach protocols results on each surface we did not identify a difference. Bed rails showed the main discordance of results within distinct protocols used, for both statistical analyses used, being a 9.7% approval rate difference and 20.5 RLU median difference. We mainly attribute this discordance to the structural complexity of the surface and material composition of the bed rails, factors that impact directly hospital bed rail cleaning, as shown by Boyle et al.7 in a previous review. This characteristic potentially interferes with the cleaning process and promotes certain variability in ATP results. Although identified an apparent difference in results for QACB and bleach protocols in bed rails cleaning, the overall cleaning result was not affected, since both protocols showed results within the established cut-off point for this surface.This study has some limitations. It is a single-centered retrospective and not controlled, which may be subjected to bias, such as register inconsistencies and cleaning process variability. The restricted number of samples was insufficient for statistical analysis per surface type and diminished the power of the analysis. We did not assess the microbiological contamination of surfaces, which could contribute to a better understanding of environmental cleanliness. Despite the limitations, our study showed a glimpse of the actual practice of hospital cleaning in the institution, indicating a satisfactory environmental cleaning and no difference in the use of distinct products, QACB or DISCUSSIONIn this study, we compared QACB versus bleach protocols for environmental cleaning of hospital wards using the ATP bioluminescence methodology and measured the approval rate of cleaning processes per protocol. No statistical difference was found (p = 0.450) between the bleach and QACB cleaning processes. Furthermore, the approval rate of cleaning processes, i.e., ATP values ≤ 100, were predominantly within the cut-off established for this study and showed similar results in both protocols.Many factors influence ATP results as distinct cleaning protocols2, surface’s nature and complexity7, and even ATP tool brand8, that promote a considerable difficulty in comparing ours and literature published results. Despite these issues, usual cut-off points of 250 or 100 RLU are used in various studies and have good acceptance for defining a clean and safe environment9,10. Smith et al.9 found an approval rate of 52% using 250 LRU as a cut-off. We use a 100 RLU cut-off point for approval of the cleaning process. We adopted a rigorous cut-off and yet we have achieved a satisfactory environmental cleanup approval rate for both protocols. The obtained results must be related to quality processes linked to the institutional environmental cleaning guide: cleaning team training, continued supervision with systematic ATP testing, feedback of results to the cleaning team, and quality control of chemical products11. We consider that simple but rigorous and systematic management of basic cleaning Silva et al.http://seer.ufrgs.br/hcpaClin Biomed Res 2023;43(2)212bleach. So, it is possible to conclude that the use of QACB or bleach protocols promote a clean and safe environment. Considering the differences in the spectrum of action of both products, further studies are necessary to analyze the interchangeability between the cleaning protocols according to the expected microbiological contamination.REFERENCES1. Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008 [Internet]. Atlanta: CDC; 2008 [cited 2022 Sep 26]. Available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html2. Dancer SJ, Kramer A. Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY. J Hosp Infect. 2019;103(1):e1-8.3. Anderson DJ, Chen LF, Weber DJ, Moehring RW, Lewis SS, Triplett PF, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017;389(10071):805-144. Mulvey D, Redding P, Robertson C, Woodall C, Kingsmore P, Bedwell D, et al. Finding a benchmark for monitoring hospital cleanliness. J Hosp Infect. 2011;77(1):25-30.5. Amodio E, Dino C. Use of ATP bioluminescence for assessing the cleanliness of hospital surfaces: a review of the published literature (1990–2012). J Infect Public Health. 2014;7(2):92-8.6. Borges RB, Mancuso ACB, Camey SA, Leotti VB, Hirakata VN, Azambuja GS, et al. Power and Sample Size for Health Researchers: uma ferramenta para cálculo de tamanho amostral e poder do teste voltado a pesquisadores da área da saúde. Clin Biomed Res. 2021;40(4):247-53.7. Boyle MA, Kearney A, Carling PC, Humphreys H. ‘Off the rails’: hospital bed rail design, contamination, and the evaluation of their microbial ecology. J Hosp Infect. 2019;103(1):e16-22.8. Assadian O, Harbarth S, Vos M, Knobloch JK, Asensio A, Widmer AF. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. J Hosp Infect. 2021;113:104-14.9. Smith PW, Sayles H, Hewlett A, Cavalieri RJ, Gibbs SG, Rupp ME. A study of three methods for assessment of hospital environmental cleaning. Healthc Infect. 2013;18(2):80-5.10. Deshpande A, Dunn AN, Fox J, Cadnum JL, Mana TSC, Jencson A, et al. Monitoring the effectiveness of daily cleaning practices in an intensive care unit (ICU) setting using an adenosine triphosphate (ATP) bioluminescence assay. Am J Infect Control. 2020;48(7):757-60.11. Doll M, Stevens M, Bearman G. Environmental cleaning and disinfection of patient areas. Int J Infect Dis. 2018;67:52-7.Received: 16 jan, 2023 Accepted: 24 mar, 2023AcknowledgmentsThe authors thank the hospital’s cleaning service for providing the database used in this study.Ethics and other permissionsThe study was approved by the Institutional Research Ethics Committee, under registration CAAE 53036721.4.0000.5327.

Evaluation of terminal cleaning using ATP methodology: comparison of bleach and quaternary ammonium compound plus biguanide

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Evaluation of terminal cleaning using ATP methodology: comparison of bleach and quaternary ammonium compound plus biguanide

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