Practical Approaches for Assessment of Daily and Post-discharge Room Disinfection in Healthcare Facilities


Purpose of Review

Cleaning and disinfection in healthcare facilities is essential to ensure patient safety. This review examines practical strategies used to assess and improve the effectiveness of daily and post-discharge manual cleaning in healthcare facilities.

Recent Findings

Effective implementation of cleaning interventions requires objective monitoring of staff performance with regular feedback on performance. Use of fluorescent markers to assess thoroughness of cleaning and measurement of residual ATP can provide rapid and objective feedback to personnel and have been associated with improved cleaning. Direct observation of cleaning and interviews with front-line staff are useful to identify variations and deficiencies in practice that may not be detected by other methods. Although not recommended for routine monitoring, cultures can be helpful for outbreak investigations.


Monitoring and feedback can be effective in improving cleaning and disinfection in healthcare facilities. Ongoing commitment within institutions is needed to sustain successful cleaning and disinfection programs.

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;6(1):130.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control. 2013;41(5):S12–S9.

    Article  PubMed  Google Scholar 

  3. 3.

    Weinstein RA, Hota B. Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis. 2004;39(8):1182–9.

    Article  Google Scholar 

  4. 4.

    Boone SA, Gerba CP. Significance of fomites in the spread of respiratory and enteric viral disease. Appl Environ Microbiol. 2007;73:1687–95.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Calvo B, Melo AS, Perozo-Mena A, Hernandez M, Francisco EC, Hagen F, et al. First report of Candida auris in America: clinical and microbiological aspects of 18 episodes of candidemia. J Inf Secur. 2016;73:369–74.

    Google Scholar 

  6. 6.

    Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 2013;34:459–65.

    Article  PubMed  Google Scholar 

  7. 7.

    Eckstein BC, Adams DA, Eckstein EC, Rao A, Sethi AK, Yadavalli GK, et al. Reduction of Clostridium difficile and vancomycin-resistant enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007;7(1):61.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Hayden MK, Bonten MJ, Blom DW, Lyle EA, van de Vijver DA, Weinstein RA. Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis. 2006;42(11):1552–60.

    Article  PubMed  Google Scholar 

  9. 9.

    Weinstein RA, Hota B. Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis. 2004;39:1182–9.

    Article  Google Scholar 

  10. 10.

    Mitchell BG, Dancer S, Anderson M, Dehn E. Risk of organism acquisition from prior room occupants: a systematic review and meta-analysis. J Hosp Infect. 2015;91(3):211–7.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Alfa MJ, Lo E, Olson N, MacRae M, Buelow-Smith L. Use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates. Am J Infect Control. 2015;43(2):141–6.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Boyce JM, Guercia KA, Sullivan L, Havill NL, Fekieta R, Kozakiewicz J, et al. Prospective cluster controlled crossover trial to compare the impact of an improved hydrogen peroxide disinfectant and a quaternary ammonium-based disinfectant on surface contamination and health care outcomes. Am J Infect Control. 2017; doi:10.1016/j.ajic.2017.03.010.

  13. 13.

    Passaretti CL, Otter JA, Reich NG, Myers J, Shepard J, Ross T, et al. An evaluation of environmental decontamination with hydrogen peroxide vapor for reducing the risk of patient acquisition of multidrugresistant organisms. Clin Infect Dis. 2013;56(1):27–35.

  14. 14.

    Boyce JM, Havill NL, Otter JA, et al. Impact of hydrogen peroxide vapor room decontamination on Clostridium difficile environmental contamination and transmission in a healthcare setting. Infect Control Hosp Epidemiol. 2008;29:723–9.

    Article  PubMed  Google Scholar 

  15. 15.

    Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis. 2010;10:197.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Anderson D, Chen LF, Weber DJ, Moehring RW, Lewis SS, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the benefits of enhanced terminal room disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017;389:805–14.

    Article  PubMed  Google Scholar 

  17. 17.

    •• Carling PC, Briggs JL, Perkins J, Highlander D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis. 2006;42:385–8. Original article describing the use of the fluorescent marker method as a tool to improve thoroughness of cleaning.

    Article  PubMed  Google Scholar 

  18. 18.

    Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren S, et al., Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:1035-4.

  19. 19.

    Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O, Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol. 2009;30:678–84.

    Article  PubMed  Google Scholar 

  20. 20.

    Branch-Elliman W, Robillard E, McCarthy G, Gupta K. Direct feedback with the ATP luminometer as a process improvement tool for terminal cleaning of patient rooms. Am J Infect Control. 2014;42:195–7.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Carling PC, Parry MF, Bruno-Murtha LA, Dick B. Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission. Crit Care Med. 2010;38:1054–9.

    Article  PubMed  Google Scholar 

  22. 22.

    Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. Am J Infect Control. 2010;38:S41–50.

    Article  PubMed  Google Scholar 

  23. 23.

    Rutala WA, Weber DJ. the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. Available at: Accessed May 10, 2017.

  24. 24.

    Donskey CJ, Deshpande A. Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: a review of the literature. Am J Infect Control. 2016;44:e17–21.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Dancer SJ. How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in hospitals. J Hosp Infect. 2004;56:10–5.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Griffith C, Cooper R, Gilmore J, Davies C, Lewis M. An evaluation of hospital cleaning regimes and standards. J Hosp Infect. 2000;45:19–28.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Havill NL. Best practices in disinfection of noncritical surfaces in the health care setting: creating a bundle for success. Am J Infect Control. 2013;41(5):S26–30.

    Article  PubMed  Google Scholar 

  28. 28.

    Goodman ER, Piatt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol. 2008;29:593–9.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrug-resistant organisms from prior room occupants. Arch Intern Med. 2011;171:491–4.

    Article  PubMed  Google Scholar 

  30. 30.

    Smith A, Taggart L, Lebovic G, Zeynalova N, Khan A, Muller M. Clostridium difficile infection incidence: impact of audit and feedback programme to improve room cleaning. J Hosp Infect. 2016;92:161–6.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Alfa MJ, Dueck C, Olson N, et al. UV-visible marker confirms that environmental persistence of Clostridium difficile spores in toilets of patients with C. difficile-associated diarrhea is associated with lack of compliance with cleaning protocol. BMC Infect Dis. 2008;8:64.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    • Kundrapu S, Sunkesula V, Sitzlar BM, Fertelli D, Deshpande A, Donskey CJ. More cleaning, less screening: evaluation of the time required for monitoring versus performing environmental cleaning. Infect Control Hosp Epidemiol. 2014;35:202–4. In an evaluation of the time required to provide monitoring and feedback on daily disinfection of CDI rooms, the investigators found that the time required for monitoring and feedback was greater than the estimated time to perform the daily disinfection. The findings demonstrate that optimizing and maintaining improvements in cleaning typically require significant ongoing efforts by infection control and/or EVS programs and highlight the potential value of forming dedicated teams of highly motivated workers for selected settings such as isolation rooms.

    Article  PubMed  Google Scholar 

  33. 33.

    Knape L, Hambraeus A, Lytsy B. The adenosine triphosphate method as a quality control tool to assess ‘cleanliness’ of frequently touched hospital surfaces. J Hosp Infect. 2015;91:166–70.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Smith PW, Beam E, Sayles H, et al. Impact of adenosine triphosphate detection and feedback on hospital room cleaning. Infect Control Hosp Epidemiol. 2014;35:564–9.

    Article  PubMed  Google Scholar 

  35. 35.

    Amodio E, Dino C. Use of ATP bioluminescence for assessing the cleanliness of hospital surfaces: a review of the published literature (1990-2012). Infect Public Health. 2014;7:92–8.

    Article  Google Scholar 

  36. 36.

    Luick L, Thompson PA, Loock MH, et al. Diagnostic assessment of different environmental cleaning monitoring methods. Am J Infect Control. 2013;41:751–2.

    Article  PubMed  Google Scholar 

  37. 37.

    Deshpande A, Sitzlar B, Fertelli D, et al. Utility of an adenosine triphosphate bioluminescence assay to evaluate disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 2013;34:865–7.

    Article  PubMed  Google Scholar 

  38. 38.

    •• Boyce JM, Havill NL, Lipka A, Havill H, Rizvani R. Variations in hospital daily cleaning practices. Infect Control Hospital Epidemiol. 2009;31:99–101. In this study, the investigators identified substantial variations in the amount of time spent cleaning surfaces, the number of disinfectant wipes used, and in the level of cleanliness achieved by different EVS workers. The findings highlight the utility of including direct observations of EVS performance in the development of educational materials and standard operating procedures for cleaning.

    Article  Google Scholar 

  39. 39.

    Rupp ME, Adler A, Schellen M, Cassling K, Fitzgerald T, Sholtz L, et al. The time spent cleaning a hospital room does not correlate with the thoroughness of cleaning. Infect Control Hosp Epidemiol. 2013;34:100–2.

    Article  PubMed  Google Scholar 

  40. 40.

    Cadnum JL, Hurless KN, Kundrapu S, Donskey CJ. Transfer of Clostridium difficile spores by nonsporicidal wipes and improperly used hypochlorite wipes practice+ product= perfection. Infection Control & Hospital Epidemiology. 2013;34(04):441–2.

    Article  Google Scholar 

  41. 41.

    Cadnum JL, Jencson AL, O’Donnell MC, Flannery ER, Nerandzic MM, Donskey CJ. An increase in healthcare-associated Clostridium difficile infection associated with use of a defective peracetic acid–based surface disinfectant. Infect Control Hospital Epidemiol. 2017;38:300–5.

    Article  Google Scholar 

  42. 42.

    Ray AJ, Deshpande A, Fertelli D, Sitzlar BM, Thota P, Sankar CT, et al. A multicenter randomized trial to determine the effect of an environmental disinfection intervention on the incidence of healthcareassociated Clostridium difficile infection. Infect Control Hosp Epidemiol. 2017;38(7):777–783. doi:10.1017/ice.2017.76.

  43. 43.

    Falk PS, Winnike J, Woodmansee C, Desai M, Mayhall CG. Outbreak of vancomycin-resistant enterococci in a burn unit. Infect Control Hosp Epidemiol. 2000;21:575–82.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Deshpande A, Kundrapu S, Sunkesula VC, Cadnum JL, Fertelli D, Donskey CJ. Evaluation of a commercial real-time polymerase chain reaction assay for detection of environmental contamination with Clostridium difficile. J Hosp Infect. 2013;85:76–8.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Mutters R, Nonnenmacher C, Susin C, Albrecht U, Kropatsch R, Schumacher S. Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction. J Hosp Infect. 2009;71:43–8.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    • Havill NL, Havill HL, Mangione E, Dumigan DG, Boyce JM. Cleanliness of portable medical equipment disinfected by nursing staff. Am J Infect Control. 2011;39:602–4. Monitoring of cleaning typically focuses primarily on high-touch surfaces in patient rooms. This article highlights the importance of including portable equipment that is shared among patients in environmental cleaning interventions.

    Article  PubMed  Google Scholar 

  47. 47.

    Suwantarat N, Supple LA, Cadnum JL, Sankar T, Donskey CJ. Quantitative assessment of interactions between hospitalized patients and portable medical equipment and other fomites. Am J Infect Control. 2017; doi:10.1016/j.ajic.2017.05.003.

  48. 48.

    Kundrapu S, Sunkesula V, Jury LA, Sitzlar BM, Donskey CJ. Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of healthcare workers’ hands. Infect Control Hosp Epidemiol. 2012;33:1039–42.

    Article  PubMed  Google Scholar 

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Corresponding author

Correspondence to Abhishek Deshpande.

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Conflict of Interest

Dr. Deshpande has received research funding from 3M, Clorox, and Steris.

Dr. Donskey has received research funding from EcoLab, Clorox, GOJO, and Altapure and serves on an advisory board for 3M.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

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This article is part of the Topical Collection on Healthcare Associated Infections

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Deshpande, A., Donskey, C.J. Practical Approaches for Assessment of Daily and Post-discharge Room Disinfection in Healthcare Facilities. Curr Infect Dis Rep 19, 32 (2017).

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  • Daily disinfection
  • Terminal disinfection
  • Hospital surfaces
  • Environmental cleaning
  • Surface hygiene