High percentage of MDROs recovered from all areas

MDRO environmental contamination is pervasive in LTC settings, and our findings are consistent with previous reports. ^{Reference Rock, Cosgrove and Keller9–Reference McKinnell, Miller and Singh10} While prior studies emphasized the need for improvements in environmental cleaning practices in LTC, this analysis, performed after the COVID-19 pandemic, when environmental cleaning was strongly emphasized, suggests opportunities for improvement remain.

While previous studies have found higher MDRO contamination in common areas, ^{Reference McKinnell, Miller and Singh10} our data showed higher MDRO positivity in resident rooms compared to common areas. It is possible that the COVID-19 pandemic may have impacted these findings. In both facilities, an additional EVS staff member was assigned a “flex” position, responsible for focusing solely on additional disinfection of common areas, hallway railings, and elevators; this intervention was implemented in response to the emphasis on environmental cleaning in the early days of the COVID-19 pandemic.

Facility 1 had a higher overall MDRO burden than Facility 2; this was likely a reflection of the acuity of the residents in each facility–Facility 1, located in an urban setting, had a higher percentage of patients undergoing hemodialysis and long-term ventilator care patients, who are more likely to harbor resistant organisms.

Higher bacterial burden in areas closest to the resident bed

Collecting composite samples of HTSs in different zones of the resident room allowed us to use this data to inform practical methods for EVS workflow. For example, quantitative bacterial burden was highest in Composite 1, which included samples closest to the resident bed. This may be because residents spend most of their time in bed and are more likely to shed bacteria in the areas directly around them. Our focus groups and observations revealed that most of the time the residents were in the room during cleaning, and staff were often hesitant to move resident belongings due to resident preferences, which impacts their cleaning process.

A mixed-methods review across Veterans Affairs long-term and acute care facilities ^{Reference McKinley, Goedken and Balkenende2} echoes these findings, which reported more effective cleaning when the patient was absent. Specific education regarding the importance of frequent and thorough disinfection of surfaces around the resident, including tray tables, bed rails, and call switches, should be incorporated into EVS staff training. Clear expectations and methods to organize resident belongings to ensure tray tables and HTSs close to the resident are cleaned may be an important area of focus. For example, providing shower caddies to organize resident belongings may help to facilitate more efficient ways to move and clean resident items.

Bacterial burden higher on long-term care units than any other sampled units

Overall bacterial burden was higher in LTC units, where residents often remain in the room for years, compared with other units, including short-stay and ventilator units. Our focus groups with supervisors and staff revealed potential causes for this accumulated bacterial burden. “Terminal” cleans, which include more in-depth cleaning of the resident room and typically require the resident to leave the room, are scheduled to occur monthly even for residents in long-term units who are not moving out of the room. Supervisors reported difficulties in both scheduling and staffing terminal cleans.

Missing or skipping terminal cleans can lead to bacterial buildup over time, and long-term units may be particularly vulnerable to this, as resident belongings may impact the ability to clean under accumulated personal effects. Incorporating clear schedules of terminal cleans into daily staffing workflow for long-term units may help alleviate some of this confusion and reduce the risk of missed or rushed terminal cleans.

MRSA most prevalent organism identified, and ventilator units more likely to have multiple MDROs

MRSA was the most prevalent organism on environmental surfaces, which is concurrent with previous studies of both resident colonization and environmental contamination in LTC. ^{Reference Kanamori, Rutala, Sickbert-Bennett and Weber11–Reference Rutala, DiBiase and Powell13} Resident rooms in ventilator units were more likely to be contaminated with 2+ MDROs. This is consistent with prior studies showing environmental contamination of the room is more likely when a resident is colonized with a resistant organism, ^{Reference Murphy, Eells and Quan12} because residents residing in ventilator units are more likely to be colonized with an MDRO due to specific risk factors (ie, higher healthcare exposure, indwelling devices).

Emphasis should be placed on the importance of frequent and thorough environmental cleaning of ventilator units and resident rooms with known colonization status, including delegation of cleaning of shared medical equipment.

Frequent practice deviations from facility policy

Our direct observations of EVS workflow showed frequent deviations from basic environmental cleaning policies, including cleaning from high areas to low areas to prevent particles falling to the floor after cleaning the floor, and cleaning from clean to dirty areas to prevent further contamination. While supervisors in focus groups clearly emphasized these policies and reported they were incorporated in basic training, interviews with EVS staff did not reflect strong knowledge of these policies. Training of EVS staff in both facilities was provided largely by shadowing, which resulted in significant variation in practices across staff members. These deviations reflect the need for more frequent observation and directed feedback by supervisors to ensure all staff are aligned on appropriate practice and are corrected prior to training new staff members. Additionally, reminders on these basic practices could be posted throughout patient rooms so that sequence of cleaning can continue to be emphasized even when supervisors are not present to correct staff.

Limitations

While we did record whether or not a resident was known to be colonized by the nursing home based on standard passive surveillance practices, the number of residents known to be colonized with an MDRO was too low to identify whether there was a significant correlation between the resident’s colonization status and MDROs found in the environment. Additionally, while our study employed a robust bacterial plating method, further assessment of the isolated bacteria through molecular speciation via direct sequencing would have improved our understanding of the range of resistant microorganisms affecting the facilities.

It is also possible that our observations underestimate deviations from policy and missed HTSs due to the Hawthorne effect, as EVS staff were aware of the observer throughout their cleaning process. Despite this, we still saw high deviations from facility policy and missed high-touch surfaces, reflecting a need to address identified barriers. While we performed this study at two facilities with different corporate structures in order to identify organization-based differences which may impact findings, additional larger studies should be implemented to augment generalizability.