Healthcare-associated infections (HAIs) have a significant impact on patients and health systems. Reference Magill, Edwards and Bamberg1,Reference Stone2 Critical to the prevention of HAIs is maintaining a clean and disinfected environment of care. In addition to environmental surfaces within the healthcare environment, noncritical portable medical equipment (PME), such as vitals machines, ultrasound machines, and stethoscopes, present an opportunity for fomite transmission of pathogens. Reference Donskey3,Reference Mullins, Burnham, Henricson, Cohen, Fair and Ray4 PME frequently comes in contact with patients, Reference Suwantarat, Supple, Cadnum, Sankar and Donskey5 but it is inconsistently cleaned and disinfected, Reference Ghumman, Ahmad, Pop-Vicas and Iftikhar6,Reference Bowe, Srivastava and Masroor7 and it serves as a potential reservoir and opportunity for onward transmission of pathogens. Reference Donskey3 In 2008, the Centers for Disease Control and Prevention (CDC) published recommendations for the cleaning and disinfection of PME. 8 Despite these recommendations, numerous studies have documented failures in cleaning and disinfection of noncritical PME that require low-level disinfection (LLD). These failures have been noted through both observed and self-reported healthcare personnel (HCP) behavior, as well as inferred by studies demonstrating contamination rates of PME between 25% and 100%, Reference Uneke9 including with clinically important pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. Reference Levin, Shatz and Sviri10
PME is increasing in volume and variety across many healthcare environments, resulting in an increase in opportunities for failures in cleaning and disinfection and the risk of transmission. A recent study in Veterans’ Affairs medical centers showed an increase in the proportion of point-of-care ultrasound (POCUS) machine availability from 29% to 71% between 2015 and 2020. Reference Williams, Nathanson and LoPresti11 This growth also occurred in emergency departments across the United States, Reference Jain, Stead and Decker12 where workflow challenges, such as high patient volume, crowding, and frequent interruptions, present barriers to routine IPC practices. Reference Liang, Riethman and Fox13
The reasons for failures in LLD of noncritical PME vary. HCP report perceived barriers to LLD that include a lack of understanding of who is responsible for LLD of PME, a lack of training for or understanding of the required LLD procedures, especially when protocols vary between equipment, as well as a lack of time and materials. Reference Muniz, Sethi, Zaghi, Ziniel and Sandora14 In this review, we examined published literature to identify educational and administrative interventions aimed at improving HCP performance of LLD of noncritical PME. Systematic reviews have been conducted regarding educational strategies for improving infection prevention broadly. Reference Safdar15 Reviews have been also conducted regarding interventions aimed at improving hand hygiene behavior Reference Price, Macdonald and Gozdzielewska16 and environmental cleaning and disinfection are limited. Reference Hewage, Cao, Jones and Fraser17,Reference Thomas, Lorenzettti and Conly18 To our knowledge, no systematic review has been published specifically targeting interventions to improve LLD of noncritical PME in the United States.
Methods
This study has been reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting standards. 19
Search strategy
In January 2023, searches were developed by a medical librarian (L.L.P.) and were executed in the Ovid Medline, Cochrane CENTRAL Registry via Ovid, Embase, CINAHL, and Web of Science Core Collection databases. The search combined keywords and database-specific subject headings for 3 concepts: disinfection, portable medical equipment, and intervention studies. A publication date range of January 1, 2006 through January 23, 2023, was applied. Literature focused on populations outside the United States were excluded. The full search strategies are included (Supplement 1 online).
Eligibility criteria
The review was limited to studies in the United States published during or after 2006, due to the release of updated CDC guidance on managing multidrug-resistant organisms in healthcare settings in that year. Reference Siegel, Rhinehart, Jackson and Chiarello20 Studies were included if educational or administrative interventions aimed at behavior change were carried out in acute or ambulatory care settings and involved LLD of PME, also described as “mobile patient equipment” or “noncritical” medical devices (NCMDs), as described in the Spaulding Classification System and the CDC Rational Approach to Disinfection and Sterilization. Reference Spaulding21,22 Studies were excluded if they took place in settings such as home healthcare or nursing homes, if they involved only semicritical or critical equipment, or if they focused on the utilization and evaluation of specific cleaning products or methods, such as UV disinfection, without inclusion of educational or administrative interventions.
Screening
The systematic review screening software Covidence (Veritas Health Innovation, Melbourne, Australia) was used for both the title and abstract screening by 3 authors (A.B., C.V.G., and M.D.) and full-text review stages (A.B. and C.V.G.). Conflicts were resolved through consensus with arbitration when needed by the senior author (E.S.S.).
Data extraction and critical appraisal
Data extraction and quality assessment were completed by 2 reviewers (A.B. and C.V.G.). Articles were dually, independently screened, and conflicts were resolved through consensus. Population, setting, year, intervention protocol, type of PME, number of participants and/or observations, and results of the intervention were extracted from eligible publications.
Quality assessment was conducted using the Johanna Briggs Institute (JBI) 9-question critical appraisal tool for quasi-experimental studies. Reference Aromataris, Fernandez, Godfrey, Holly, Khalil and Tungpunkom23 These assessments were conducted independently by each reviewer and then resolved through consensus (Supplement 2 online).
Results
The database searches retrieved 2,198 citations (Fig. 1). Duplicate citations were removed using Endnote reference software, resulting in 1,493 citations for title and abstract screening. Of these, 1,416 studies were subsequently excluded during title and abstract screening. Of 77 publications that were assessed for eligibility in a full-text review, 68 were excluded, resulting in 9 studies that were further evaluated. Reference Holleck, Campbell and Alrawili24–Reference Jordan, Barrett, Murney, Whipp and Elliott32 From these, 1 study was later excluded after data extraction and critical appraisal as it did not meet the quality assessment inclusion criteria (Supplement 2 online). Reference Jordan, Barrett, Murney, Whipp and Elliott32
Figure 1. PRISMA flow diagram. Diagram illustrates the selection of studies included in this review.
Each of the 8 included studies described an educational intervention to improve disinfection practices of noncritical PME. Studies included a variety of PME: 3 included stethoscopes Reference Holleck, Campbell and Alrawili24–Reference Holleck, Merchant, Lin and Gupta26 ; 2 included POCUS machines Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 ; 1 included ultrasound equipment Reference Pessin and Matthews29 ; 1 included vitals machines, ultrasound machines, and bladder scanners Reference Reese, Knepper and Kurtz30 ; and 1 included vitals machines (VMs) and workstations on wheels (WOWs). Reference Crowley, Chatterjee and Coppin31 Seven studies were conducted in hospital settings, Reference Holleck, Campbell and Alrawili24–Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28,Reference Reese, Knepper and Kurtz30,Reference Crowley, Chatterjee and Coppin31 and 1 study was conducted in a student sonography laboratory. Reference Pessin and Matthews29 Four studies described the use of a combined, multimodal intervention, Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Holleck, Merchant, Lin and Gupta26,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28,Reference Reese, Knepper and Kurtz30 and 4 studies described a single intervention strategy. Reference Holleck, Campbell and Alrawili24,Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Pessin and Matthews29,Reference Crowley, Chatterjee and Coppin31 Details of the interventions and reported outcomes are provided in Table 1.
Table 1. Interventions Implemented for Improving Compliance With Cleaning and Disinfecting PME, and Whether These Interventions Were Successful in Effecting Change in Behavior
Note. DTS, disinfection tracking system; PME, portable medical equipment; POCUS, point-of-care ultrasound; RLU, relative light unit; VM, vitals machine; WOW, workstation on wheels.
Interventions
Intervention strategies included luminescence or other visual indicators of contamination, surveillance and feedback, visual reminders in the environment of care, the strategic placement of materials needed for LLD, or educational modules [eg, a short PowerPoint (PPT) presentation or an educational website].
Overall, 3 studies used luminescence tools, including Glo Germ Powder (Glo Germ Company, Moab, UT) and ATP bioluminescence, to visually demonstrate or simulate contamination of PME to HCP as part of a single educational intervention and/or ongoing education, surveillance, and feedback. Reference Holleck, Campbell and Alrawili24,Reference Pessin and Matthews29,Reference Reese, Knepper and Kurtz30 Of these 3 studies, 1 study also used culturing to visually demonstrate contamination of PME to participants. In 1 study, a disinfection tracking system (DTS) was used as a visual intervention. The DTS was a small device attached to the PME that monitored disinfection and indicated on a screen when the last disinfection event on the PME had occurred. Reference Crowley, Chatterjee and Coppin31
Three studies strategically placed LLD supplies and visual LLD reminders near where LLD should take place. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Holleck, Merchant, Lin and Gupta26,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 Of these, 2 studies introduced baskets of alcohol wipes outside patient rooms accompanied by visual reminders for stethoscope LLD. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Holleck, Merchant, Lin and Gupta26 One of these studies coupled this intervention with an educational presentation on stethoscope hygiene. Reference Holleck, Merchant, Lin and Gupta26 In another study, a website was created to provide educational materials, supplemented with an informational placard and the provision of appropriate disinfectant wipe canisters affixed to the PME. Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28
Finally, one study utilized a short PPT presentation aimed at providing education on multiple aspects of PME handling, including LLD. Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27
Reported outcomes
Of the 8 studies included in the review, 4 studies were successful in improving LLD practices, with their respective interventions involving luminescence, workflow changes, and educational sessions. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28–Reference Reese, Knepper and Kurtz30 Also, 2 studies were unclear about the success of the intervention; 1 study involved the DTS; and the other involved an educational PPT. Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Crowley, Chatterjee and Coppin31 In the DTS study, only the DTSs on the WOWs documented more cleaning events, but the DTSs on VMs did not. Reference Crowley, Chatterjee and Coppin31 In the study with an educational PPT, disinfection improved from 61% before the intervention to 66% after the intervention, but the statistical significance of this change was not calculated. Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27 The 2 studies focused on cleaning and disinfection of stethoscopes that failed to demonstrate improvement were conducted by the same research team. These researchers used a workflow improvement and educational session in one study and cultures or bioluminescence before and after LLD to demonstrate contamination in the other. Reference Holleck, Campbell and Alrawili24,Reference Holleck, Merchant, Lin and Gupta26
Study duration and sustainability
Of the 8 included studies, 4 were between 4 and 14 weeks in duration Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25–Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Crowley, Chatterjee and Coppin31 ; 2 studies did not specify their duration Reference Holleck, Campbell and Alrawili24,Reference Pessin and Matthews29 and 2 studies were conducted over longer periods (1 year, 30 months). Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28,Reference Reese, Knepper and Kurtz30 In only 1 study was follow-up data collected during a maintenance period. This study demonstrated the sustainability of the effects of their intervention; maintenance data were collected for 6 months after a 6-month implementation period. Reference Reese, Knepper and Kurtz30 In the other 7 studies, before-and-after data were collected without an assessment of long-term sustained improvement. Reference Holleck, Campbell and Alrawili24–Reference Pessin and Matthews29,Reference Crowley, Chatterjee and Coppin31
Luminescence and visual indicators
Of the 4 studies involving visual indicators of contamination, 2 reported successful interventions, Reference Pessin and Matthews29,Reference Reese, Knepper and Kurtz30 the DTS study showed mixed success, Reference Crowley, Chatterjee and Coppin31 and 1 study was entirely unsuccessful in causing a change in behavior in HCP. Reference Holleck, Campbell and Alrawili24
Combined, multifaceted interventions
Of the 8 studies, 4 included a combination of 1 or more of the interventional strategies described above. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Holleck, Merchant, Lin and Gupta26,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28,Reference Reese, Knepper and Kurtz30 One of these studies combined ongoing education with ongoing ATP bioluminescence feedback on performance. Reference Reese, Knepper and Kurtz30 In another study, in addition to their targeted educational campaign, access to cleaning products was increased by ensuring that appropriate wipes were stocked directly on the POCUS units themselves. Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 In a third study, access to stethoscope cleaning supplies was improved and visual reminders regarding stethoscope hygiene were introduced. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25 In a fourth study, reminder signage was installed and boxes of alcohol wipes were made available at the entrances to patient rooms in addition to an educational intervention. Reference Holleck, Merchant, Lin and Gupta26 Of these combined intervention studies, 3 showed improvement in either observed LLD of PME or the objective measurements of cleanliness of PME. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28,Reference Reese, Knepper and Kurtz30 In the fourth study, no change in stethoscope hygiene was achieved, and the intervention was discontinued after 1 month. Reference Holleck, Merchant, Lin and Gupta26
Four studies described a single intervention type. Reference Holleck, Campbell and Alrawili24,Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Pessin and Matthews29,Reference Crowley, Chatterjee and Coppin31 Of these 4 studies, 3 showed some improvement in observed LLD of PME, objectively measured cleanliness of PME, or in the case of the DTS, objective measurement of cleaning events. Reference Prats, Nelson, Gold, Branditz, Boulger and Bahner27,Reference Pessin and Matthews29,Reference Crowley, Chatterjee and Coppin31 Notably, in 1 study, the effect of a Glow Powder exercise on LLD techniques by sonography students was investigated, but these students were also receiving infection prevention and control (IPC) education as part of their sonography training during the study, which may have affected the findings. Reference Pessin and Matthews29
HCP beliefs and reported barriers to LLD of PME
Of the 8 studies included in the review, 3 studies included surveys and/or needs assessments of HCP beliefs regarding the importance of LLD of PME, as well as their perceived barriers to doing so. Reference Holleck, Campbell and Alrawili24,Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 Two groups of researchers used survey data or conducted needs assessments to inform targeted interventions. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 Two groups surveyed participants before and after their interventions to demonstrate the influence of their intervention on the knowledge and attitudes of their staff. Reference Holleck, Campbell and Alrawili24,Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 One group of researchers designed their intervention to address 2 important barriers identified in a previous survey they had conducted on stethoscope hygiene at the same institution: lack of access to disinfection supplies and lack of visual reminders to disinfect. Reference Zaghi, Zhou, Graham, Potter-Bynoe and Sandora25 Another study created their targeted intervention to change physician POCUS LLD behavior based on the outcomes of a needs assessment conducted with these physicians. Reference Van Kalsbeek, Enroth, Lyden, Rupp and Smith28 A third study’s pre- and post-survey results demonstrated an improvement in providers’ reported belief in the importance of stethoscope hygiene after their educational intervention, as well as an increase in the self-reported frequency of LLD. However, observed behavior did not improve after the intervention. Reference Holleck, Campbell and Alrawili24 Using a survey, this study identified that lack of available LLD supplies was among the top 3 barriers to stethoscope hygiene, but this barrier was not addressed in the intervention and it remained among the top 3 barriers in the postintervention survey. Reference Holleck, Campbell and Alrawili24
Quality assessment
The results of the critical appraisal are provided in Supplement 2 (online).
Discussion
Although failures in cleaning and disinfection of noncritical PME have been well documented, our review of published literature revealed a paucity of studies assessing the impact of educational and administrative interventions to improve practice. Across the included interventions, however, the features of those that were successful in improving the LLD of PME are notable.
The successes of 2 of the 4 study interventions involving visual indicators of contamination, Reference Pessin and Matthews29,Reference Reese, Knepper and Kurtz30 and mixed success of the DTS in one of these studies, Reference Crowley, Chatterjee and Coppin31 suggest that providing HCP visual evidence or simulation of contamination can be an effective method in influencing behavior. In one study that was unsuccessful at changing behavior, the visual indicators did appear to change beliefs in the importance of cleaning and disinfection of PME, and staff responded in a survey that seeing the ATP results from their own PME was more influential in motivating them to clean and disinfect stethoscopes than peer-reviewed literature. Reference Holleck, Campbell and Alrawili24
Based on this review, multimodal interventions that include a combination of educational strategies appear to be more effective in improving behavior regarding LLD practices, which is supported by existing approaches. The 2017 World Health Organization “Core Components of Effective Infection Prevention and Control Programs” suggests the value of multimodal programs to improve IPC practice. Reference Storr, Twyman and Zingg33 Multimodal interventions have been successfully employed to address other challenging areas of IPC compliance, such as hand hygiene. Reference Patrick, Hess, Cooper, Rock, Doll and Bearman34 Four of the included studies took this approach, whereas 4 studies employed 1 strategy alone. The study that demonstrated the largest impact on LLD included an ongoing, multimodal intervention including weekly ATP bioluminescence surveillance, feedback, and education over a 6-month period involving both managers and staff. Reference Reese, Knepper and Kurtz30 This finding is consistent with the findings of a recent review of factors associated with improved environmental cleaning and disinfection practices more broadly. This study described the most successful interventions as those that combined education and training with the provision of feedback, as well as those that utilized continuous education and training. Reference Hewage, Cao, Jones and Fraser17
Interventions that address the needs and perceived barriers HCP face in implementing LLD require further investigation to identify how these may influence compliance with LLD and the sustainability of these improvements.
This analysis had several limitations. A small number of studies ultimately met criteria for inclusion, limiting the ability to draw broader conclusions. This lack of studies demonstrates an important gap in our understanding of effective interventions. Studies conducted outside the United States were also excluded. The frequency and duration of interventions were varied across the included studies, limiting ability to draw any conclusions related to optimal frequency and duration of educational interventions. Lack of long-term follow-up further limited assessment of the impact of interventions over time and the sustainability of any improvements.
In conclusion, as the use of PME in healthcare continues to expand, and care is delivered in ever more complex and diverse environments, the need to understand how to optimize HCP education, training, and competency in LLD has never been greater. Ensuring correct and consistent LLD of PME will be essential to patient safety. This review revealed that studies examining educational interventions to improve LLD of PME are limited; further investigation to demonstrate effective teaching modalities is needed. In particular, randomized control trials of educational and administrative interventions and studies that demonstrate the sustainability of interventions to improve LLD of PME are needed. Studies of interventions to improve environmental cleaning and LLD of equipment should provide data on equipment and environmental surfaces separately to better elucidate the impact of interventions on the practice of LLD across surfaces in the patient environment.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2023.234
Acknowledgments
The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or of the Massachusetts General Hospital. The authors are sincerely grateful to Hang Lee, PhD for his help with the critical appraisal of statistical analysis in the included articles.
Financial support
This work was supported by a cooperative agreement from the Centers for Disease Control and Prevention to Massachusetts General Hospital (CK22-2203).
Competing interests
All authors report no conflicts of interest relevant to this article.
