Not all Fluorescent Marker Systems are Created Equal!
Variability in Fluorescent Marker Removal from Healthcare Environmental Surfaces.
Authors: Peter Teska, B.S.; MBA, Kathryn Fischer, B.S.; Salah Qutaishat, PhD, FSHEA, CIC
Diversey, Inc., Sturtevant, WI
Background/Objectives:
Pathogens causing Healthcare Associated Infections (HAIs) may come from a number of
sources, but are believed to be transmitted to sites leading to infection via Healthcare worker
(HCW) hands1. Hospital patients shed pathogens into their immediate environment, but there
is debate about the role contaminated environmental surfaces play in the subsequent development of HAIs2, largely due to the complexity of determining causality. Despite this issue,
it is now widely accepted that contaminated environmental surfaces and equipment, along
with contaminated HCW hands, play a role in the transmission of pathogens causing HAIs in
patients3-6.
It has been demonstrated that current cleaning practices are suboptimal, with typical compliance by workers tasked with cleaning environmental surfaces in patient rooms less than
50%7. Carling8 recommended the use of a fluorescent marker (FM) to help evaluate cleaning
compliance and to provide direct feedback to workers on their performance. The CDC in its
2010 recommendations9 includes the use of an FM as a component of a program to audit the
compliance of Environmental Services (EVS) staff in performing routine cleaning and disinfection of Healthcare environmental surfaces.
However, ease of removal of the FM from environmental surfaces has not been evaluated
previously. Lack of removal of the FM from an environmental surface can be due to a failure
on the part of the worker in cleaning the surface, but it can also be due to the inability of the
standard cleaning process to remove the FM. There are currently no standards for ease of
removal of an FM from an environmental surface.
In this study we examined the amount of variability in the inherent removability of the FM
from four common Healthcare environmental surfaces (ES) by looking at the removability of
six commercially available FMs.
Methods:
We tested the removability of six commercially available FM on the following four common
healthcare environmental surfaces: bedrail, toilet seat, acrylic Plexiglas, and hand soap dispenser. Samples of the surfaces were obtained from local suppliers. Surfaces were cut into
1.5”x1.5” pieces and all testing was run in triplicate.
The FM was applied directly to pieces of the four surfaces and allowed to dry. A black light
was used to verify the FM was properly applied to the surface. The surface was then cleaned
with a microfiber cloth wetted with the use solution of a neutral disinfectant cleaner (NDC)
prepared according to manufacturers’ label directions by wiping several times in the same
direction on the surface. The black light was used to determine whether the FM was removed
(pass) or not removed (fail). If the FM was removed, the piece was set aside.
If the FM was not removable with a NDC, we repeated the cleaning and verification with a
stronger General Purpose Cleaner using the method above. The removal was again visually
assessed using the black light and rated as either removed (pass) or not removed (fail). If the
FM was removed, the piece was set aside.
If the FM was still not removable, we repeated the cleaning and verification with a strong
highly alkaline solvent containing “power cleaner” using the method above. The removal
was again visually assessed using the black light and rated as either removed (pass) or not
removed (fail).
In this matter, we created a ladder of increasing strength of cleaning ability to determine the
strength of chemistry necessary to remove the FM from a given surface when marked with a
given FM if not initially removed by the NDC.
Results:
Table 1. Fluorescent Marker Removal From Four Surfaces Using Neutral
Disinfectant Cleaner.
Fluorescent Marker
Healthcare Environmental Surfaces
Toilet Seat
Plexiglas
Bed Rail
Hand Soap
Sanitizer
Overall
Rating
trapping the dye in the wiping cloth and thus removing it from the surface.
The use of the stronger cleaner in the study demonstrated that removal from the surface
was not solely linked to the strength of the chemistry used for cleaning. This demonstrates a
relationship between the FM and an inherent binding to the surface, which may interfere with
FM removal. For the three FMs not initially removable from all four ES, stronger chemistry
improved the removal on the problem surfaces, but for one of the FMs, still did not remove the
FM from all surfaces.
Fluorescent Marker 1
Yes
Yes
Yes
Yes
Pass
Fluorescent Marker 2
Yes
Yes
Yes
Yes
Pass
Fluorescent Marker 3
Yes
Yes
Yes
Yes
Pass
Conclusion:
Fluorescent Marker 4
No
No
No
No
Fail
Fluorescent Marker 5
No
Yes
No
No
Fail
Fluorescent Marker 6
No
No
No
No
Fail
Before implementing a program to measure thoroughness of cleaning by using an FM, a
Healthcare facility should test their selected FM to ensure of its removal from all environmental surfaces to be monitored.
References:
Table 2: Results of the Fluorescent Marker Removal Using General
Purpose Cleaner.
Fluorescent Marker
Healthcare Environmental Surfaces
Toilet Seat
Plexiglas
Bed Rail
Hand Soap
Sanitizer
Overall
Rating
Fluorescent Marker 4
Yes
Yes
Yes
No
Fail
Fluorescent Marker 5
No
N/A
No
No
Fail
Fluorescent Marker 6
Yes
Yes
No
No
Fail
Table 3: Results of the Fluorescent Marker Removal Using Power Cleaner.
Fluorescent Marker
Healthcare Environmental Surfaces
Toilet Seat
Plexiglas
Bed Rail
Hand Soap
Sanitizer
Overall
Rating
Fluorescent Marker 4
N/A
N/A
N/A
Yes
Pass
Fluorescent Marker 5
No
N/A
No
Yes
Fail
Fluorescent Marker 6
N/A
N/A
Yes
Yes
Pass
Discussion:
This study showed wide variations in removability of the various FMs on common Healthcare
environmental surfaces with 3 of 6 (50%) FMs removed from all four test surfaces using a
NDC. It also showed that using stronger cleaner/disinfectants may improve removability of FM
from some surfaces, but was no guarantee. Some commercially available FMs are not easily removable from common Healthcare environmental surfaces and are not appropriate for
Healthcare facilities.
Poor removability of the FM on a given surface can be the result an inherent lack of removability of the FM due to issues with binding to the surface or previous damage to the surface,
which can increase the surface absorptivity or the surface roughness, making it impossible to
reach the FM during cleaning and effect removal.
The removability of an FM from an environmental surface during cleaning is achieved through
a combination of a chemical and mechanical process. The use of a cleaning product, such as
a neutral disinfectant cleaner, provides emulsification of the fluorescent dye that is dried onto
the surface. The wiping cloth provides a mechanical action to remove the solubilized dye,
1.World Health Organization. Clean Care is Safer Care Team, Report on the Burden of
Endemic Health Care-Associated Infection Worldwide. Geneva, Switzerland: WHO
Document Production Services; 2011.
2.Otter JA, Yezli S, French GL, The Role Played by Contaminated Surfaces in the
Transmission of Nosocomial Pathogens. Infect Control Hosp Epidemiol, 2011;32:687-699.
3.Huslage K, Rutala WA, Gergen MF, Sickbert-Bennett EE, Weber DJ, Microbial Assessment
of High, Medium, and Low Touch Hospital Room Surfaces. Infect Control Hosp Epidemiol,
2013;34:211-212.
4.Huang SS, Datta R, Platt R, Risk of Acquiring Antibiotic-Resistant Bacteria From Prior
Room Occupants. Arch Intern Med, 2006;166:1945-1951.
5.Drees M, Snydman DR, Schmid CH, Barefoot L, Hansjosten K, Vue PM, et al, Prior
Environmental Contamination Increases the Risk of Acquisition of Vancomycin-Resistant
Enterococci. Clin Infect Dis, 2008;46:678-685.
6.Otter JA, Yezli S, Salkfeld JAG, French GL, Evidence that contaminated surfaces contribute
to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control, 2013;41:S6-S11.
7.Carling PC, Parry MF, Von Beheren SM, Identifying Opportunities to Enhance
Environmental Cleaning in 23 Acute Care Hospitals. Infect Control Hosp Epidemiol,
2008;29:1-7.
8.Carling PC, Briggs JL, Perkins J, Highlander D, Improved Cleaning of Patient Rooms Using
a New Targeting Method. Clin Infect Dis, 2006;42:385-388.
9.Guh A, Carling PC, Environmental Evaluation Workgroup, Options for Evaluating
Environmental Cleaning. Dec 2010;1-15. Downloaded from http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html, Mar 7, 2014.