title: The adenosine triphosphate method as a quality control tool to assess 'cleanliness' of frequently touched hospital surfaces.
abstract: BACKGROUND
  The adenosine triphosphate (ATP) method is widely accepted as a quality control method to complement visual assessment, in the specifications of requirements, when purchasing cleaning contractors in Swedish hospitals.
  
  
  OBJECTIVE
  To examine whether the amount of biological load, as measured by ATP on frequently touched near-patient surfaces, had been reduced after an intervention; to evaluate the correlation between visual assessment and ATP levels on the same surfaces; to identify aspects of the performance of the ATP method as a tool in evaluating hospital cleanliness.
  
  
  METHODS
  A prospective intervention study in three phases was carried out in a medical ward and an intensive care unit (ICU) at a regional hospital in mid-Sweden between 2012 and 2013. Existing cleaning procedures were defined and baseline tests were sampled by visual inspection and ATP measurements of ten frequently touched surfaces in patients' rooms before and after intervention. The intervention consisted of educating nursing staff about the importance of hospital cleaning and direct feedback of ATP levels before and after cleaning.
  
  
  RESULTS
  The mixed model showed a significant decrease in ATP levels after the intervention (P < 0.001). Relative light unit values were lower in the ICU. Cleanliness as judged by visual assessments improved. In the logistic regression analysis, there was a significant association between visual assessments and ATP levels.
  
  
  CONCLUSIONS
  Direct feedback of ATP levels, together with education and introduction of written cleaning protocols, were effective tools to improve cleanliness. Visual assessment correlated with the level of ATP but the correlation was not absolute. The ATP method could serve as an educational tool for staff, but is not enough to assess hospital cleanliness in general as only a limited part of a large area is covered.
authors.affiliation: Centre of Research & Development, Uppsala University/County Council of Gävleborg, Uppsala, Sweden.
authors.forename: L
authors.initials: L
authors.lastname: Knape
authors.affiliation: Department of Medical Sciences, Clinical Bacteriology, Uppsala University, Uppsala, Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Hambraeus
authors.affiliation: Department of Medical Sciences, Clinical Bacteriology, Uppsala University, Uppsala, Sweden. Electronic address: birgitta.lytsy@akademiska.se.
authors.forename: B
authors.initials: B
authors.lastname: Lytsy
mesh_terms: D000255:Adenosine Triphosphate / Q000032:analysis*; D004783:Environmental Microbiology; D006761:Hospitals; D006797:Housekeeping, Hospital / Q000379:methods* / Q000592:standards*; D006801:Humans; D017053:Infection Control / Q000379:methods* / Q000592:standards*; D008828:Microbiological Techniques / Q000379:methods*; D011446:Prospective Studies; D011786:Quality Control; D013548:Sweden
chemical_list: D000255:Adenosine Triphosphate
keywords: Adenosine triphosphate; Education; Hospital cleaning; Visual inspection