Cleaning C. difficile – Whose job is it anyway?
Excerpts from a teleclass lecture by Dr. Michelle Alfa, Winnipeg, Man.

Toilets and commodes are probably the most heavily soiled and contaminated surfaces in the room of a patient infected with (itals)Clostridium difficile(enditals). And there is potential for a disastrous outbreak if the proper cleaning isn’t happening. Although it sounds like a rhetorical question – whose job is it? – what you think is happening, may not actually be happening.

The toilets in most healthcare facilities are the responsibility of the housekeeping staff to clean. In my own facility the protocol is that the toilets are cleaned once a day on the wards and throughout the hospital. If the patient is diagnosed with (itals)Clostridium difficile(enditals) Associated Diarrhea (CDAD), that is bumped up to twice daily cleaning of their bathroom area, morning and afternoon. Our infection control protocol recognizes that the toilets need to be kept as clean as possible to reduce the risk for transmission.

To test the bathroom cleaning compliance of housekeeping staff in the rooms of CDAD patients we use a water-soluble UV marker to “inoculate” various surfaces of the toilet seat. The marks show up as fluorescent whirls under UV light, but are invisible under normal light. The fresh marks are considered 100 per cent fluorescence,  and even a simple wipe with a damp cloth can remove 50 per cent of the mark. We allowed the housekeepers to clean the toilets as they normally would unaware of the mark, and then viewed and evaluated residual fluorescence. We discovered that the cleaning efficacy of toilets in CDAD isolation rooms averaged 56.5 per cent, whereas a regular non-isolation room averaged 72.9 per cent. Rather than increased cleaning and decontamination, toilets in isolation rooms were cleaned less carefully. We can only speculate that the cleaners wanted to get in and out of the isolation room quickly and thereby rushed the decontamination procedure.

Commodes are notorious for moving between rooms. Of course it is important that once a patient is diagnosed with CDAD, if they need a commode, it is dedicated to their room and not shared between patients in multiple rooms. If the commode is handy to the patient, who will have frequent and sudden bouts of diarrhea, there won’t be a temptation for a worker to rush into another room for a commode. The question again is: who is designated as responsible for cleaning the commodes? It was a surprise to use to find out that everybody thought everybody else was doing it, and in the end, nobody was doing it because it had not been designated as a responsibility.

If no one is designated to clean the commodes, they may not be cleaned at all, or they may be cleaned very sporadically. You may think that in your policy you have toilet cleaning once or twice a day as a routine, but the commodes are on of those little cracks in the sidewalk. If nobody is actually aware that they are responsible for it, the cleaning of commodes will get lost in the busy-ness of modern healthcare.