Environmental Services Line Personnel – A presentation should be developed for all line staff involved in terminal room cleaning and should:
Many hospitals have provided a small (possibly ES staff-language specific) pictorial booklet to the environmental services personnel at the conclusion of the presentation which is often developed to be language skill appropriate.
ES managers – As senior managers will be actively involved in the design and implementation of either Level I or Level II programs, educational interventions for them will need to be customized. While many of these individuals have an excellent understanding of the basic policies and procedures involved in terminal room cleaning, most will benefit from focused educational interventions related to our evolving understanding of the role of the environment in healthcare-associated pathogen (HAP) transmission. Evaluation of mid-level managers also needs to be customized. Most importantly, the impact of the program on mid-level ES managers needs to be monitored since additional formal and informal education is frequently needed for those individuals who are somewhat unsure of the importance of developing programmatic approaches to optimize terminal room cleaning.
Other groups – Given the overall importance of optimizing the thoroughness of hygienic practice in healthcare settings, hospital specific educational interventions graphically illustrating the impact of the program should be considered for both Level I and Level II programs. Such communications should be developed for a range of audiences within the hospital including the senior hospital administration, the medical staff, nursing personnel on the units, executive nursing and medical staff committees and the hospital’s board of managers or directors.
In considering implementation of a Level II program, the advantages and limitations of various monitoring approaches must be considered carefully. The factors which distinguish each approach to Level II monitoring are discussed below and summarized in Fig.1. With any method or methods used it is important that neither the system itself (fluorescent marker) nor its use (precleaning cultures or ATP measurements) induce a Hawthorne type effect.
Direct Practice Observation – Covert monitoring of disinfection cleaning can provide an objective assessment of individual ES staff performance and compliance with cleaning protocols. This approach has been used to objectively evaluate and improve ICU environmental hygiene in one hospital. While conceptually feasible, logistical issues related to maintaining such a program outside a research setting may limit adaptation of this form of Level II monitoring. Furthermore, the complexity of monitoring cleaning practice in individual patient rooms without the evaluator being recognized as such might represent a difficult confounding issue.
Swab Cultures – While several outbreak intervention studies have associated decreased environmental contamination by target organisms as a result of modified cleaning practice leading to decreased acquisition of targeted pathogens, none of the reports specifically note if serial environmental culture results were actually used to provide practice feedback to the ES staff. Although swab cultures are easy to use, the cost of processing, including isolate identification, the delay in analyzing results, the need to determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice, and the limited feasibility of monitoring multiple surfaces in multiple patient rooms as part of an ongoing Level II monitoring program represent issues which could limit the broad application of this system.
Agar Slide Cultures – Agar coated glass slides with finger holds were developed to simplify quantitative cultures of liquids. The slides have been adopted for use in environmental surface monitoring in healthcare settings. These studies have used agar coated slide systems to evaluate cleaning practice by quantifying aerobic colony counts (ACCs) per cm.[2,3] While studies have measured aggregate ACCs before and after cleaning, no studies to date have evaluated the actual thoroughness of cleaning of the same objects to determine if objects with relatively high ACCs were either poorly cleaned or actually overlooked by the ES staff. Although some difficulties have been encountered in utilizing the agar slide cultures on other than large, flat surfaces, they potentially provide an easy method for quantifying viable microbial surface contamination. There is a need, similar to that noted above for swab cultures, to determine pre-cleaning levels of contamination for each object evaluated in order to accurately assess cleaning practice.
Fluorescent Markers – Fluorescent gel, powder, and lotion have all been developed for the purpose of marking high touch objects prior to room cleaning.
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