Are the Towels in Your Hospital Really Clean?

Investigators Find Dangerous Microbes

By ALISON McCOOK

Clean towels are clean, right?

Several years ago, a group of investigators set out to answer that question. They collected three cleaned towels from 10 Arizona hospitals, submerging each towel in buffered peptone water to extract microbes. They wrung out each towel, collected the broth and examined it for signs of potentially dangerous microbes.

The investigators found them.

More than 90% of the towels contained viable microbes, including 3% with the potentially dangerous bacteria Escherichia coli. Furthermore, more than half of the buckets used to soak towels in disinfectants—the very containers designed to clean the towels—harbored viable bacteria, including those that form spores (Am J Infect Control 2013;41[10]:912-915).

The results are among a body of research that points to a troubling trend: The products used to clean medical facilities may be contributing to their contamination. Now, researchers are asking themselves how to do a better job of cleaning hospital cleaning products.

‘We’re cleaning up after people, and people leave behind a lot of stuff—everything from small bits of human skin and hair to bacteria, fungi and viruses ... In some cases, the contamination level was too high to count with the traditional and molecular methods we were using.’ —K. Mark Wiencek, PhD

In the 2013 study, the researchers examined reusable cloths made of cotton and of microfiber, common materials used in cleaning products. Both were contaminated. Roughly 10 years ago, microfibers came onto the market, promising to do a better job of picking up soil and weighing less than cotton, the typical material of cleaning products such as mops and rags (Am J Infect Control 2007;35[9]:569-573).

Since then, hospitals rapidly added them to their roster of cleaning products. But then they came across a dilemma: The laundry techniques that kill microbes—bleach and hot water— also destroy the delicate microfibers. The gentle cleaning process that microfibers need doesn’t always destroy the contamination on the surface of used cleaning products. Now that the world is dealing with an ongoing COVID-19 pandemic, adopting the best products and practices for cleaning has become even more crucial.

The situation has left facilities scrambling for solutions. “We’re finding lots of contamination in the very tools we are using to clean,” said K. Mark Wiencek, PhD, the lead microbiologist at Contec, Inc., a company headquartered in Spartanburg, S.C., that manufactures cleaning supplies. “As a result, we are faced with this conundrum of how to properly decontaminate these towels and mops without destroying the textile.”

A Fine Mess

A microfiber mop that’s been used to clean a hospital floor is, simply put, pretty gross.

“We’re cleaning up after people, and people leave behind a lot of stuff—everything from small bits of human skin and hair to bacteria, fungi and viruses,” Dr. Wiencek said. He and his colleagues have repeated the 2013 experiment, testing mops and towels from hospitals after laundering. “In some cases, the contamination level was too high to count with the traditional and molecular methods we were using,” he said.

Microfiber initially works better than cotton, but after multiple washes and if laundered improperly microfiber may not perform as well (Am J Infect Control 2010;38[4]:289-292), noted Karen deKay, MSN, RN, CNOR, CIC, a perioperative practice specialist at the Association of periOperative Registered Nurses.

Most facilities likely use a variety of materials to clean between patients, she said. In the perioperative environment, for instance, most places employ single-use disinfectant cloths made of

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Value Over Volume Reimagining Health Care Through The Lens of Systems Science

By BRUCE RAMSHAW, MDB

When the parts of our health care system are motivated by volume and revenue growth, the result of the whole system is represented in the figure (below).

Every country in the developed world has an unsustainable slope of increasing per capita spending on health care. Each part of the system is successfully hitting revenue and growth targets, guaranteeing the unsustainability of the system as a whole.

If private insurers raise rates and decrease benefits each year, hospitals continue to increase revenue and volume, physicians continue to hit increasing relative value unit targets, and pharmaceutical and device companies continue to hit increasing quarterly Wall Street revenue targets, what else do you think would happen at the whole system level? An unsustainable increase in global per capita spending is predictable because our health care system is designed around financial growth rather than patient care.

Our health care system, particularly hospitals and academic medical centers, may be in the most complex of all industries and organizations in our world. But these organizations are designed in a reductionist system structure that leads to increased fragmentation when complexity is increased.

The current reductionist organizational structure in health care evolved with no attention to the vast diversity of patient populations and increasing complexity of problems that are seen in a typical medical center. The result is more fragmentation manifested by an everincreasing number of department silos that are not designed around each definable patient care process. It would be like a car manufacturing plant that functioned in department silos: one department for tires, one for engines, one for steering wheels, etc.

8000

7000

6000

5000

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1000 US NOR SWIZ NETH CAN DEN GER FR SWE UK AUS NZ JPN

0 1980 1984 1988 1992 1996 2000 2004 2008 Year

Figure. Average spending per capita by country, adjusted for the cost of living.

Source: Organisation of Economic Cooperation and Development Health Data, June 2011 These department silos would not communicate well with each other, yet they would be expected to make flawless automobiles. The first automobile on the manufacturing line is intended to be a sports car; the next is a school bus, the next is a tow truck, the next is an

SUV, and so on. It would be a disaster. By continuing to address increasing complexity with reductionist structural solutions, the harm and waste we see in health care are guaranteed.

This fragmentation also leads to system tools being designed inappropriately into the fragments of care rather than for whole patient care processes. For example, electronic health record systems are designed for the fragments of care, primarily with the purpose of documentation for coding and billing. By only collecting data for a fragment of care, it’s not possible to measure the outcomes for any whole patient process. This prohibits the appropriate measurement of value-based outcomes and the appropriate analysis that could be applied to learn how to better measure and improve outcomes.

So, if volume is an unsustainable strategy, what is a sustainable strategy? Value.

The language about the transformation of health care from volume to value is all over the place. But the understanding of how to do this and the science behind why we should do this are still not well understood.

Sadly, no hospital that I know of has made this transition yet. For the good of our patients and our physicians and clinical teams, this transition is essential. The continued focus on volume (an extrinsic