Monitoring Hospital Cleanliness with Standardised ATP Measurements

Denmark introduces official guidelines for Adenosine-Triphosphate (ATP) tests

Dennis Andersen (Andersen Control Aps) Denmark
Aims
To make a guideline to the Danish Standard for cleaning in the health care sector EN/DS 2451- Table 1
10[1] that combines the visual control with a quantitative measuring method for the nonvisible
contamination- and transmission risk. OBJECT BEFORE AFTER CLEANING
CLEANING
Introduction and background Table by sink (305-258-351) (49-16-81)
The DS 2451-10 standard describes requirements for cleaning with a view to preventing
infections. These requirements build on scientific documentation or broad consensus based on the Door handle
(1600-831-2369) (19-13-24)
experience of specialists in the fields of cleaning and infection prevention in the health care sector. wardroom
•International studies show there is a connection between resources for cleaning and acquired
Bed lamp (327-233-421) (23-10-36)
infections in the health care sector. This should influence the resource allocation priorities for
cleaning [2][3][4]. With this standard, it will be possible to establish levels for the cleanliness of Bedside table (293-193-393) (27-13-41)
surfaces and to obtain recommendations for work processes leading to the achievement of the
established hygiene levels. Levels and work processes for cleaning and quality control contributes Wall rail (1489-330-3648) (34-17-50)
to eliminating infectious matter, thus helping to prevent infections.
•The transmission risk inherent in what is not related to spillage, and which is therefore not visible, Tap handle (461-79-842) (157-44-269)
has been a matter of great interest to the working group with a view to finding reliable and Total average 746 51
approved methods to map out risks and provide guidance on these risks. From visual inspection,
the possibilities of inspecting infection hygiene have moved via biological inspection to Sample size (n) 13 12
microbiological inspection. The standard includes a biological inspection method, Adenosine
Triphosphate (ATP), as well as microbiological inspection methods, dip slide or contact plates.

Methods Table 2 shows the ATP level[6] for the stated hygiene levels at the critical risk points, expressed in
The inspection method for ATP has been included as an informative annex (annex D in the femtomole. Femtomole is often converted into RLU (Relative Light Unit). The conversion factor
standard) due to the fact that, at the date of publication of the standard (2011), there was not depends on the measurement equipment. The Femtomole limit values are the results of the
sufficient experience in the health care sector with using this method. The reason it has proposed values in the literature of 500 and 250 RLU, divided with 10 since the ATP equipment in
nevertheless been included is the desire to contribute tools enabling a future framework for the studies has a conversion factor of 1 to 10. [7][8]
collecting data which may shed light on the relationship between a not visible contamination and Using a luminometer of which the scale of RLU corresponds to the amount of femtomol
transmission risk and thus to be able to determine sufficient cleaning methods and the need for eliminates the need for conversion.
resources for cleaning. Table 2, femtomol ATP limit values
The fields of application are the 10 critical risk points, in the literature named hand-touch sites[5],
lighting near the patient, patient rest, hand sink and water tap, screens, other sanitation, grips, Critical risk points Hygiene level 5 Hygiene level 4&3
tables, stands, technical installations near the patient and other technical installations. The
probability for presence of infectious matter and the relevant critical risk points for each type of Light near patient <25 <50
room is stated in the annex A in the standard. There are in total five hygiene levels, but only the
Patient rest <25 <50
three top levels (5,4,3) are relevant for quantitative measure, since there are no patients present in
the two lowest levels (1,2). Level 5 is care/treatment areas and production areas requiring a Hand sink & water tap <25 <50
particularly high degree of cleanliness. Level 4 and 3 are primarily patient-related areas. Screen <25 <50
To secure that the limit values where achievable, a small-scale study was performed at the Other sanitary items <25 <50
Aarhus University Hospital, Skejby at two following days in the same wardroom (Y2, 220). ATP
Grips <25 <50
levels were determined using ‘Cleantrace’ swabs and a Uni-Lite NG luminometer (Biotrace
International Ltd, Bridgend, UK) over an area of 100 cm2 in a close zigzag pattern using the Tables <25 <50
manufacturer’s guidelines and expressed as relative light units (RLU) with a conversion factor of 1 Stands <25 <50
femtomol ATP to 10 RLU. 50 time laundered Viima® Glass cloths from ‘De Forenede Technical installations near patient <25 <50
Dampvaskerier A/S’ was used for cleaning. The special construction of 50% polyester and 50%
Other technical installations <25 <50
polyamide, 16 piece split fibre in the cloth has given the cloth ability to in vitro tests (EN 13697) to
reduce e.g. the log count from log7 to Log1 for staphylococcus aureus. It was therefore expected a In case a result between 25 and 50 femtomol is obtained at a Hygiene 5 level location, this
similar high reduction in ATP amount. Results are presented in table 1. requires further observation. A result above 50 femtomol requires intervention.
In following studies the ‘Ultrasnap’ swabs and a SystemSURE Plus luminometer (Hygiena In case a result between 50 and 100 femtomol is obtained at a Hygiene level 4 and 3, this
International Ltd, Watford, UK) were used. This system has a conversion factor of 1 femtomol ATP requires further observation. A result above 100 femtomol requires intervention.
to 1 RLU, which means the RLU scale corresponds to the amount of femtomol ATP (results not Example:
shown). A wardroom, which is hygiene level 3, has the limit of 50 femtomol in each critical risk point.
Finding result in e.g. a hand sink higher than 50, means that you should observe and see if
further measuring indicates that cleaning is out of control. Results higher than 100 means that
you have to make a cause analysis to correct and prevent the error if possible.

Discussion and conclusion

Results
The small-scale study in table 1 shows that it is possible to achieve a significant reduction in
the RLU value, by using ultra effective micro fibre without detergent or disinfectant, but just
water. It was therefore according to reduction in figure 1 concluded to state the limit values as
reachable as presented in the literature.
The maximum level for ATP should according to previous proposal[7][8][9] not exceed 500 or 250
RLU per 100 cm2. However studies[10] show that the limits should be investigated. The standard
proposes the cleanliness levels according to table 2 knowing that there can be challenges to reach
these limits for certain types of surfaces and materials[11][12]. However the small-scale study in
table 1 show that the impact of ultra efficient cleaning methods can perform even lower ATP
amount after cleaning. The question is no longer if there should be a limited value for ATP, since it
has been proved a valid method to evaluate cleaning methods and resources needed for sufficient
results[13], but rather how it is possible to secure satisfying results on different materials and
surfaces using correct cleaning methods.

References
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