Patient room cleaning: the daily clean, and how to show it was done

01

What patient room cleaning is, and the rules behind it

Hospitals clean a patient room in two different ways. The daily clean, also called routine or occupied room cleaning, is done while the patient is admitted. The discharge clean, or terminal cleaning, is done after the patient leaves and reaches everything, including the mattress, the bed frame and the vents. This guide is about the first.

The CDC's Environmental Cleaning Procedures define it plainly: "Routine cleaning of inpatient areas occurs while the patient is admitted, focuses on the patient zones and aims to remove organic material and reduce microbial contamination to provide a visually clean environment." The same page adds that "systems should be established to ensure that cleaning staff have reasonable access to perform routine cleaning." They were written for facilities with limited resources, but their structure suits any U.S. program.

No federal rule sets a checklist for the daily clean. The duty sits in broader requirements:

• Hospitals. Under 42 CFR 482.42, the Medicare Condition of Participation for infection prevention and control and antibiotic stewardship programs, a hospital's programs "must demonstrate adherence to nationally recognized infection prevention and control guidelines," and at 482.42(a)(3) must include "maintaining a clean and sanitary environment to avoid sources and transmission of infection."
• Nursing homes. 42 CFR 483.80, Infection control, requires a program "designed to provide a safe, sanitary, and comfortable environment," and the resident rights at 42 CFR 483.10(i) require "Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior" and "Clean bed and bath linens that are in good condition."
• The people doing the work. OSHA's Bloodborne Pathogens standard, 29 CFR 1910.1030, says at (d)(4)(i): "The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area." The daily patient room clean belongs in that written schedule. In a state with an OSHA-approved State Plan, the state's equivalent standard applies; OSHA lists 22 State Plans covering private and public sector workers and seven covering only state and local government workers.

The guideline most programs point to is the CDC and HICPAC Guidelines for Environmental Infection Control in Health-Care Facilities (2003). Accreditors such as The Joint Commission survey against their own paid standards; work from your current copy.

02

What the daily clean covers, and how often

The CDC procedures set minimum frequencies for inpatient areas. For the room itself, high-touch surfaces and floors are cleaned "At least once daily (e.g., per 24-hour period)," low-touch surfaces on a "Scheduled basis (e.g., weekly) and when visibly soiled," and handwashing sinks at least daily. A private patient toilet is cleaned and disinfected at least once daily, after the patient care area; a shared or public toilet at least twice daily.

The CDC's environmental guideline explains why the frequency differs by surface. It says that "high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact." In practice the daily clean of an occupied room usually covers:

• The patient zone: bed rails and bed controls, the overbed tray table, the call button and its cord, the TV remote, the telephone, the bedside table and its handle, the chair arms.
• The wider room: door handles and push plates, light switches, the hand hygiene dispenser, the thermostat, the computer or workstation on wheels if EVS is assigned it, the edges of the privacy curtain, and any other furniture people touch.
• The sink: basin, faucet handles and the surrounding counter, with soap and paper towels refilled.
• The bathroom: grab bars, the toilet seat and flush handle, the wall around the toilet, the shower controls, the sink, the door handle on both sides.
• Trash and soiled linen removed, liners replaced, and full sharps containers reported or exchanged under the facility's policy.
• Horizontal surfaces such as window sills, on the scheduled cycle and whenever soiled.
• The floor, dust mopped and damp mopped last.

Some things are cleaned when they need it rather than every day. The CDC guideline says: "Cleaning of walls, blinds, and window curtains is recommended when they are visibly soiled." A spill of blood or body fluid is cleaned at once, whatever the schedule: OSHA's standard at (d)(4)(ii)(A) requires contaminated surfaces to be decontaminated "immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials."

03

How to clean a patient room: the order of work

The CDC procedures give three strategies that apply to every clean. Work from cleaner to dirtier, finishing with the surfaces the patient touches most and the bathroom. Work from high to low, to "prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas." And work in a systematic manner, "left to right or clockwise," so that nothing is missed and the next technician does the room the same way.

A daily clean that follows those strategies usually runs like this:

1. Check the door for isolation signage and put on the PPE it calls for. Perform hand hygiene.
2. Knock, introduce yourself, and ask whether now is a good time. If not, set a time to come back.
3. Remove trash and soiled linen, and replace liners.
4. Wet a fresh cloth in the solution and fold it to about the size of your hand, as the CDC procedures describe, turning it to a clean side as you go.
5. Clean high surfaces outside the patient zone first, then door handles, light switches and the dispenser.
6. Clean the patient zone with a fresh cloth: bed rails, bed controls, tray table, call button, remote, phone, bedside table, chair.
7. Clean the sink and restock soap and towels.
8. Clean the bathroom last of the surfaces, from the cleanest item to the toilet.
9. Mop the floor from the far corner toward the door, and put out a wet floor sign.
10. Remove PPE, perform hand hygiene, and tell the patient you are finished.

Cleaning comes before disinfection. A disinfectant applied over soil is weakened by it, so visible dirt is removed first, and then the disinfectant is applied and left wet. EPA's page of Selected EPA-Registered Disinfectants puts it simply: "The contact time is the time the product must remain on the surface for it to be effective," and "if the product label has a contact time of 10 minutes for a particular pathogen, the surface should remain visibly wet for at least 10 minutes after application of the product." A wipe that dries in one minute on a product with a longer contact time has not disinfected the surface.

Solutions and cloths carry their own risk. The CDC guideline says "Cleaning solutions should be replaced frequently," and that "Laundering of cloths and mop heads after use and allowing them to dry before re-use can help to minimize the degree of contamination." A cloth carried from room to room spreads what it picks up, so use a fresh one per room.

04

Who does what in a patient room

A patient room is shared ground, and the most common gap is an item everyone assumes someone else cleans. The CDC's C. auris guidance names the problem: outbreak investigations found that "healthcare personnel are not always aware of their responsibilities for cleaning mobile and shared equipment," and it says "Responsibilities for cleaning all mobile and reusable equipment should be well-established." A workable split, written down unit by unit, looks like this:

• The EVS technician (housekeeper or environmental services aide) cleans the room surfaces, the bathroom and the floor to the written procedure, with the right product and PPE, and reports what cleaning cannot fix: a torn mattress cover, a dripping faucet, a broken call cord.
• Nursing cleans the patient care equipment agreed as theirs, such as IV pumps, monitors and blood pressure cuffs; tells EVS when a room goes on or comes off precautions; and asks for a spot clean when something is spilled.
• The EVS lead or supervisor assigns rooms, handles refusals and callbacks, and inspects a share of finished rooms.
• The infection preventionist sets the standard with EVS, approves products, and runs or reviews the checks of how well rooms are cleaned.
• Facilities or maintenance repair what the technician reports, through a work order.

OSHA covers the technician too. Staff with occupational exposure need bloodborne pathogens training at initial assignment and at least annually under 29 CFR 1910.1030(g)(2)(ii). Under the Hazard Communication standard, 29 CFR 1910.1200, safety data sheets must be "readily accessible during each work shift," and employees trained on the chemicals in their work area "at the time of their initial assignment."

05

Checking that patient rooms are cleaned well

A disinfected tray table and a wiped tray table look the same. That is why the CDC's C. diff guidance asks facilities to "Create daily and terminal cleaning protocols and checklists for patient-care areas and equipment," and to audit the adequacy of room cleaning using the methods in the CDC's Options for Evaluating Environmental Cleaning toolkit. The toolkit is written for terminal cleaning, but its methods are also used to spot-check daily cleans, alongside the supervisor's own rounds:

• Direct observation of a technician working through a room, which shows technique, order and contact time.
• Fluorescent markers placed on high-touch surfaces before the clean and checked under UV light afterward.
• ATP readings, which measure organic residue left on a surface; see the guide on ATP testing.
• Supervisor inspection of a sample of rooms each shift, against the same list the technician works to, which shows what was missed but not whether a surface was disinfected.

The patient's view counts too. The CMS HCAHPS survey, "the first national, standardized, publicly reported survey of patients' perspectives of hospital care," asks patients about the cleanliness of the hospital environment, and CMS publishes each participating hospital's results on Care Compare.

Good evidence answers four questions for every room, every day: was it cleaned, when, by whom, and if not, why not. A sampled audit shows how well rooms are cleaned, not whether room 412 was cleaned yesterday. Feed results back to the technicians; results used to catch people out teach them to clean for the auditor.

06

Where the patient room record fails, and what SiteClara does about it

The record of a daily clean is often a tick on an assignment sheet filled in at the end of the shift. It does not show that room 412 was skipped because the patient was in dialysis and never revisited, that a C. diff room was wiped with the general disinfectant, or that the dripping faucet the technician noticed was mentioned at the nurses' station and forgotten.

SiteClara records checks at the place they happen. A printed QR code poster, with an optional NFC tag behind it, goes where a check is scheduled, such as a patient room door, a bathroom or a soiled utility room. The EVS technician scans the code or taps the tag on their own phone, with no app to install, sees the checks set for that place, and marks each one done, or says what stopped them, such as a patient who asked them to come back later. The facility decides what the check asks for, so a precautions room can ask which product was used, with a photo when one is asked for. The time and the named person are recorded as it happens. A problem found on the way, such as a broken call cord or a leaking faucet, goes onto the team's list of jobs until someone closes it.

The EVS supervisor sees what is due, done and missed, and records the reason when a check was missed. Each day they review the totals and photos and approve a report that goes the next morning to nominated managers, such as the EVS director. It shows what was reported, completed and still open, and how the scheduled checks went, with the reasons for any that were not done.

07

Questions people ask

What is the correct order for cleaning a patient room?

Clean to dirty, high to low, and in the same direction every time. The CDC's Environmental Cleaning Procedures say to "Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms" and to "Clean patient areas (e.g., patient zones) before patient toilets." For the discharge clean they set the order within the room: shared equipment and common surfaces first, then surfaces touched during patient care outside the patient zone, and finally the surfaces and items the patient touches directly.

What is it called when you clean hospital rooms?

There are two names for two jobs. The CDC's Environmental Cleaning Procedures call the clean done while the patient is admitted routine cleaning, often called daily or occupied room cleaning, and the clean after the patient leaves terminal cleaning, which "occurs after the patient is discharged/transferred, includes the patient zone and the wider patient care area and aims to remove organic material and significantly reduce and eliminate microbial contamination to ensure that there is no transfer of microorganisms to the next patient."

What are the CDC guidelines for hospital cleaning?

The one most programs work from is the CDC and HICPAC Guidelines for Environmental Infection Control in Health-Care Facilities (2003), whose environmental services section says that "high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact." The CDC's Environmental Cleaning Procedures add minimum frequencies and the order of work, and organism-specific guidance, such as the pages on C. diff and C. auris, covers rooms on precautions.

08

Where to read more, and a patient room cleaning checklist

The CDC's Environmental Cleaning Procedures give the frequencies and the order of work; the Guidelines for Environmental Infection Control in Health-Care Facilities give the principles; the CDC's guidance on C. diff and C. auris and EPA's lists K and P cover the rooms on precautions. For the discharge clean, see the guide on terminal cleaning.

Before your next survey or contract review, check that:

• the daily patient room clean is written into the cleaning schedule 29 CFR 1910.1030(d)(4)(i) requires, with its frequency, method and product;
• high-touch surfaces and floors are cleaned at least daily, the private bathroom at least daily and shared toilets at least twice daily;
• the order is clean to dirty, high to low and in the same direction every time, with the bathroom and floor last;
• each disinfectant is used to its label and stays wet for its full contact time;
• precautions rooms are cleaned after other areas with their own supplies, a List K product in C. diff rooms and a List P product in C. auris rooms;
• the split between EVS and nursing for every item in the room is written down, unit by unit;
• a room refused, occupied or skipped is recorded with a reason and a time to return, not left blank;
• every room leaves a record of when it was cleaned and by whom, and a missed room is recorded as missed.