The document summarizes studies on cleaning methods in hospital patient care areas. It describes two paradigm shifts: 1) Moving from string mops to flat microfiber mopping systems, and 2) Changing from detergent-based cleaners to detergent-free cleaners with bleach. The studies found that flat mopping systems improved ergonomics, reduced costs from lower chemical/water use and labor savings. Using detergent-free cleaners with bleach in a two-step process improved cleaning of high-touch surfaces compared to detergent-based cleaners, as measured by ATP bioluminescence.

1. GREENING OF
HOSPITALS WORKSHOP
Cleaning of Surfaces in Patient Care
Areas
Results From New Hospital Studies

2. Two Paradigm Shifts in Patient Room
Cleaning
 1st Going from the string mop to the flat mop
system for floor cleaning
 2nd Moving from cleaning patient areas with a
detergent + disinfectant to a detergent-free
cleaner + bleach

3. Paradigm Shift #1
Using Flat (Microfiber) Mopping
Systems in Hospitals

4. Take Home Message
1. Practical, common-sense approach for
patient care areas, but WILL NOT meet
all mopping needs.
2. Immediate water and chemical savings,
but most cost savings are a result of
reduced labor.
3. Improved ergonomics and cross-
contamination infection control
4. Proactively address potential hurdles to
implementation.

5. Mopping Requirements
 Patient care areas
cleaned daily; common
areas cleaned more often
 Floor cleaners can
contain dangerous
chemicals
 Special precautions
required to avoid cross-
contamination

6. Why Hospitals Switch to Flat Mopping Systems
 Ergonomic issues
 Labor savings
 Reduced chemical and water usage
 Cross-contamination concerns
related to conventional mopping

7. What is Microfiber?
1/100th of human hair
1/100th of human hair
Split wedged shape
Split wedged shape
of Polyester fiber
of Polyester fiber

8. What is Microfiber?
String Mop Strand
Human Hair
Microfiber
Hook Feature
(1/10th of a human hair) (Cross-section)

9. …and what difference does it make for mopping?
 Increases the effective surface area
of your mop
 More effective in cleaning up
especially small particles
 Microscopic fibers
thoroughly clean
surfaces

10. Flat Mopping Systems: How Do They Work?
1. Place
2. Mop
3. Peel
4. Launder

11. vs. Conventional Loop Mops
1. Dip and Wring
2. Mop
3. Repeat 3x
4. Change Water
5. Send to Industrial Laundry

12. Ergonomic Benefits
 During use, similar gross
motor skills required
 Unfavorable positions for
both methods, but flat
mopping systems
significantly reduced the
frequency and severity of
the risk factors
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

13. Ergonomic Analysis
Tasks String Mopping Flat Mopping
Lift empty
Lift metal bucket (5 lbs) Lift plastic basin (1 lbs)
metal/plastic bucket
Trunk flexion 60° Trunk flexion neutral
from cart
Carry empty Forces at trunk,
Negligible forces
bucket/basin and walk shoulders, elbow, hands
(carrying 1 lb)
3 feet (carrying 5 lbs)
Forces acting on neck,
Fill and lift Less forces acting due
back, hands, wrist,
bucket/basin to lower weight (8 lbs)
shoulders (water 16 lbs)
Upper body posture is
Flexion of trunk, hips,
neutral; less forces
Lift bucket of water, knees, shoulders.
acting on trunk, wrist,
walk to cart Forces at trunk, wrist,
shoulder, and lower
shoulder, elbow
body
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

14. Ergonomic Analysis
Tasks String Mopping Flat Mopping
Carry bucket of water, Forces at trunk, wrist,
No longer performed
walk to cart shoulder, and elbow
Lift bucket of water Wrist and elbow flexion.
and place on cart Forces acting as No longer performed
surface previously.
Walk to closet for
Neck extension, hips
bottle of cleaning
flexion, shoulder flexion Same
solution on shelf.
120°
Reach and grasp.
Add cleaning solution Neck extension, hips
and replace bottle on flexion, shoulder flexion Same
shelf 120°
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

15. Ergonomic Analysis
Tasks String Mopping Flat Mopping
Trunk flexion 80°, elbow
Pick up wringer and
flexion 60°, shoulders
hook it onto lip of No longer performed
flexion 80°. Forces
bucket
acting at trunk.
Walking with trunk Walking with trunk
Push cart to room, flexion 30°, shoulder and flexion neutral. Pushing
distance 25’ elbow flexion 80°. cart with standard
Forces acting at trunk. equipment.
Palmar grasp, shoulder
Remove excess water elevation and flexion, Wring cloth, wrist/hand
from mop elbow flexion (using mop twisting with grip force
wringer)
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

16. Ergonomic Analysis
Tasks String Mopping Flat Mopping
Mopping the floor Trunk flexion Trunk flexion
Place mop in bucket of
Turn mop head
water, wring, and
downside up and
Mopping the floor continue mopping.
replace cloth at mop
Same risks as previous
head
steps
“Case Study: Are Microfiber Mops Beneficial for Hospitals?" Sustainable Hospitals Project

17. Microfiber Considerations
 Cannot be used in areas
contaminated with blood
or body fluid
 Some products
ineffective in greasy,
high traffic kitchen areas
 Sticky floors? Non-industrial washing
machines must be used to
wash microfiber mop heads

18. CA DHS – Licensing and Certification March 2002
Memo:
“…acceptable to install household washing
machines to launder microfiber mops…”
provided:
 Water Temp between 130 and 140 degrees F
 Separately from other textiles
 No bleach/fabric softener
“…as long as (these conditions) are met,
there should be no infection control related
issues.”

19. Not All Mopping Systems
are Created Equal…
 No governing body or industry
definition of “microfiber”
 Density of fibers per square inch can
affect pricing and cleaning ability
 …vs denier (diameter of fiber)
 Some are pretreated with
antimicrobials

20. Should I Use Disinfectants
for Cleaning Floors?
 Some microfiber products are treated with
triclosan or other antimicrobials
 Concerns about general use of
antimicrobials
 Potential for causing
antimicrobial resistance
 Unknown long term
consequences of its use

21. How many mops handles/heads needed?
Mop Handles = Number of Janitors
Mops Heads =
+ twice the number of rooms
cleaned daily
+ “shrinkage”
+ special circumstance – large
rooms, extra dirty rooms

22. Case Study: University of California Davis Medical Center
 Reasons for change…
 Increase in worker’s
compensation claims
 Frequent “light duty”
ergonomic requirements
 Reduce cleaning time
for patient rooms
 Reduce chemical use
and disposal

23. Cost Analysis: Lifetime Mop Costs
Conventional Wet Microfiber
Loop Mops Mops
 $5 each  $4.00 each
 55 to 200 washing  500 to 1,000 washing
lifetime lifetime
 22 rooms cleaned per  1 room cleaned per
washing washing
 $0.11 to $0.41 per  $0.40 to $0.80 per
100 rooms 100 rooms

24. Cost Analysis: Chemical Costs
Conventional Wet Microfiber
Loop Mops Mops
 10.5 ounces per day  0.5 ounces per day
 $0.22 per ounce  $0.22 per ounce
 20 rooms cleaned per  22 rooms cleaned per
day day
 $11.55 in chemicals  $0.50 in chemicals
per 100 rooms per 100 rooms

25. Cost Analysis: Water Use
Conventional Wet Microfiber
Loop Mops Mops
 21 gallons per day  1 gallon per day
 20 rooms cleaned per  22 rooms cleaned per
day day
 105 gallons of water  5 gallons of water
used per 100 rooms used per 100 rooms

26. Cost Analysis: Labor Costs
Conventional Wet Microfiber
Loop Mops Mops
 20 rooms cleaned per 8  22 rooms cleaned per 8
hour shift hour shift
 $12 per hour  $12 per hour
 $480 per 100 rooms  $436 per 100 rooms

27. Flat Mopping Systems Performance Summary
 Microfiber last 5 to 10 times longer
 Increase production by 10%
 Use 95% less chemical
 (2.5 vs. 53 ounces per 100 rooms cleaned)
 Use 95% less water
 (5 gals vs. 105 gals per 100 rooms cleaned)
 Overall costs about 5-10% less - not including
workers comp savings

28. Costs/Benefits That Are Not Quantified
 Reduced risk of cross-
contamination related to
mopping
 Reduced worker’s
compensation claims
 Reduced water use
 Patients say: “quieter,
quicker, less disruptive”

29. Discussion
1. Who’s currently using microfiber
mops?
2. How satisfied are you with them in
patient care areas?
3. What hurdles did you have to
overcome?
4. What have you seen as the greatest
benefit to using microfiber mops?

30. Take Home Message
1. Practical, common-sense approach for
patient care areas, but WILL NOT meet all
mopping needs.
2. Immediate water and chemical savings, but
most cost savings are a result of reduced
labor.
3. Improved ergonomics and cross-
contamination infection control
4. Proactively address potential hurdles to
implementation.

31. Resources
EPA Factsheet
http://www.epa.gov/region/waste/p2/projects/hospital/mops.pd
f
Sustainable Hospitals 10 reasons to use microfiber mops
http://www.sustainablehospitals.org/PDF/tenreasonsmop.pdf
Practice Greenhealth
http://www.h2e-online.org/docs/h2emicrofibermops.pdf

32. The Need for Action
 The number of Healthcare Acquired
Infections is too high
 Even with interventions:
 Hand hygiene education
 Gel stations installed throughout patient care areas
 Closer oversight of drug administration
 HAIs and associated deaths continue
 Cost of a patient room runs $9,462 per day

33.  Unnecessary Deaths: The Human and
Financial Cost of Hospital Infections
 By Betsy McCaughey, Ph.D.
 HAIs are the fourth largest killer in America
 HAIs add an estimated $30.5 Billion to the cost of
healthcare in the US each year
 There is compelling evidence that nearly all
HAIs are preventable
 This creates a new legal issue

34. Estimated Hospital Cost of HAIs
2,000,000 Estimated HAIs per year in USA
X
$15,275.69 Average additional hospital costs per HAI
= $30.5 Billion Per year treating HAIs

35. Cleaning is Essential
 Cleaning hands is the first step – preventing
recontamination is the second
 Two studies showed that over half of objects
that should have been cleaned or disinfected
were overlooked
 As long as surfaces in a hospital are not
cleaned, caregivers’ hands will be
recontaminated

36. Cleaning of Environmental Surfaces
is Essential
 Cleaning of environmental surfaces is so
important that if not done properly, the
placing of a patient into a room previously
occupied by a patient with C-diff can be a
fatal error

37. Studies of Patient Room Cleaning
 Studies undertaken by HospAA of two-step
cleaning process
 Studies measured the current cleaning prior
to implementing the two-step cleaning
process
 Current process used cleaners with quaternary
ammonium disinfectant
 This process leaves a residue that can lead to a
biofilm

38. Paradigm Shift #2
Two-Step Cleaning
 First step: Clean to remove biofilm with non-
detergent cleaner that contains 218 ppm bleach
 Sodium Chloride is used to soften water
 Sodium Citrate is used to chelate hard water mineral
deposits
 Sodium Carbonate is used to saponafy organic soils into
soaps that are easily rinsed
 Sodium Bicarbonate is used as a builder and sequester
 Second step: Wipe the 14 HROs with bleach of
1,000 ppm

39. How Detergent-Free Cleaners Work
 Cleaning is defined as: the ability to clean or remove soil from
a surface
 Accomplished by one or more of the following
 Lowering surface and interfacial tensions
 Solubilization of soils
 Emulsification of soils
 Suspension of removed soils
 Saponification of fatty soils
 Inactivation of water hardness
 Neutralization of acid soils

40. Background for Studies
 Used luminometers manufactured by 3M to
measure adenosine triphosphate (ATP)
 ATP measured in relative light units (RLUs)
 The 14 high risk objects (HROs) outlined by
Dr. Philip Carling in his studies were
measured

41. ATP Luminometer

42. Carling’s 14 High Risk Objects
 Objects:
 Sink  Visitor Chair Arm Rest
 Toilet Seats  Patient Telephone
 Over Bed Tray  Rest Room Door Knob
 Bed Side Table  Restroom Hand Rail
 Toilet Handle  Bedpan Cleaner
 Bed Side Rail  Patient Room Door Knob
 Nurse Call Box  Restroom Light Switch

43. Using the ATP Swab

44. Results of Studies
 Three hospitals: Tested a minimum of 25 terminally
cleaned rooms in Phase I
 1,011 measurements made of the 14 HROs
 Mean Measurement was 441 RLU
 Worst HROs:
 Nurse Call Box 900 RLU (N=75)
 Patient Telephone 742 RLU (N=68)
 Visitor Chair Arm Rest 624 RLU (N=75)
 Bedside Rail 503 (N=77)
 Rest Room Door Knob 489 RLU (N=53)
 Sink/Counter 445 RLU (N=79)
 Rest Room Hand Rail 411 RLU (N=76)

45. Efforts to Standardize Studies
 Attempted to measure a minimum of 25
terminally cleaned rooms in each phase
 No disturbance of patients
 The room was ready for re-occupancy
 Trained staff doing ATP measurements
 Uniformity in swabbing
 Focused on the worst of Dr. Philip Carling’s 14
HROs
 Sampled with staff and monitored results

46. Results From Four Hospitals
 Phase I (cleaner/quaternary ammonium
disinfectant) (N= 408)
 Worst Five measured at each facility
 Mean 1,360 RLU (r=468 RLUs – 2,290 RLUs)
 Phase II (DFC + bleach) (N= 412)
 Mean 143 RLU (r=89 RLUs – 199 RLUs)

47. Four Hospital Study Results
HRO RLUs Before* RLUs After*
(Phase I) (Phase II)
Restroom Door Knob 1,934 89
Nurses Call Box 2,290 143
Patient Telephone 1,126 104
Bed Side Rail 983 164
Visitor Chair Arm Rest 1,045 199
Restroom Hand Rail 486 143
Sink/Counter 468 127
* These are Mean scores in RLUs

48. Four Hospital Cleaning Study
2,500
2,000
Relative Light Units (RLUs)
1,500
Prior Cleaning
Tw o-step Cleaning
1,000
500
0
NURSE CALL BOX VISITOR CHAIR ARM PATIENT TELEPHONE BED SIDE RAIL RESTROOM HAND RESTROOM DOOR SINK/COUNTER
REST RAIL KNOB
High Risk Objects (HROs)

49. Percent of Samples Found “Clean”
 A surface is deemed to be clean at a reading
of 250 RLU or less using the 3M luminometer
 Results from the four hospital studies:
 Phase I: Found 25.0% were below 250 RLU
 Phase II: Found 87.4% below 250 RLU

50. Four Hospital Cleaning Study
100.0%
90.0%
80.0%
70.0%
60.0%
Percent
Prior Cleaning
50.0%
Tw o-Step Cleaning
40.0%
30.0%
20.0%
10.0%
0.0%
<250 RLUs 250 - 499 RLUs 500 - 999 RLUs ≥1,000 RLUs
Relative Light Units (RLUs)

51. Future Patient Rooms

52. Continuous Improvement
 Train EVS staff in use of DFC + bleach
 Use ATP monitoring to measure change
 Continue use of ATP monitoring for training
and quality assurance
 Monitor HAIs
 Develop a Process Improvement Story