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        Methods of a study of terminal cleaning of patient rooms
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        Methods of a study of terminal cleaning of patient rooms
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To the Editor—It is encouraging to see that people have reviewed our article “Increased Time Spent on Terminal Cleaning of Patient Rooms May Not Improve Disinfection of High-Touch Surfaces.”1 However, a related Letter to the Editor raises concerns that some may be misinterpreting both the thrust of our paper and our study methodology.2

In our pragmatic report, we aimed to promote better cleaning by presenting research results that suggest that more than adequate time spent on terminal cleaning may not result in additionally lower bioburden on high-touch surfaces. We hope this information will cause practitioners to focus on other important factors such as proper training for environmental services staff (EVS), proper use of appropriate chemicals, and targeting high-touch surfaces that pose the greatest risk for transmission of pathogens to patients. We reiterated that adequate cleaning time is crucial, and we certainly do not advocate taking any shortcuts in the terminal cleaning process. Yet, as in many things, it is the quality of the process not the quantity that counts.

As to methodology, EVS were well-trained and experienced, and they voluntarily collaborated on the project. They were instructed to follow the manufacturer’s guidelines for application and contact time. We did not monitor EVS during room cleaning to avoid the Hawthorne effect and to obtain data on unmonitored cleaning.

The 5 high-touch surfaces chosen were the highest-touch surfaces according to published papers at the time of the study.3 We omitted details on the culture process and instead referenced a prior paper.4

Our analysis plan followed best practices for analyzing count data: use a generalized linear model with appropriate choice of family and link function, and avoid log transforming the data.5 We used Bayesian models and reported uncertainty in our estimates, rather than rely on a p-value. Recent articles highlight the pitfalls of statistical significance, which can be particularly problematic in small observational studies without preregistration.6 Major journals are now requiring some form of uncertainty interval rather than P values.7 We also chose to include model estimates on the actual outcome scale. This makes interpretation easy for those familiar with the outcome (ABC counts from press plates) but not familiar with statistical terminology like incident rate ratios. Our goal was to apply the best methods of analysis and interpretation.

Finally, we provided a full financial support disclosure statement in our article. The salary support for this study was provided by the authors’ employers.

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans’ Affairs. Xenex Healthcare Service did not participate in study design or in the collection, analysis, and interpretation of data or in the writing of the report or in the decision to submit the paper for publication.

Financial support

This study was supported by a merit review grant from the Department of Veterans’ Affairs to J.Z. (grant no. IIR 12-347), and laboratory activity was supported by a grant from Xenex Healthcare Services, with additional support from the Central Texas Veterans’ Health Care System (Temple, TX), Scott & White Healthcare (Temple, TX), and the jointly sponsored Center for Applied Health Research (Temple, TX).

Conflicts of interest

All authors declare no competing interests.

References

1.Coppin, JD, et al.Increased time spent on terminal cleaning of patient rooms may not improve disinfection of high-touch surfaces. Infect Control Hosp Epidemiol 2019;40:605606.
2.Hooker, EA.Increased time spent on terminal cleaning of patient rooms may not improve disinfection of high-touch surfaces. Infect Control Hosp Epidemiol 2019;40:1086.
3.Huslage, K, Rutala, WA, Sickbert-Bennett, E, Weber, DJ.A quantitative approach to defining “high-touch” surfaces in hospitals. Infect Control Hosp Epidemiol 2010;31:850853.
4.Jinadatha, C, Villamaria, FC, Ganachari-Mallappa, N, et al.Can pulsed xenon ultraviolet light systems disinfect aerobic bacteria in the absence of manual disinfection? Am J Infect Control 2015;43:415417.
5.O’Hara, RB, Kotze, DJ.Do not log-transform count data. Methods Ecol Evol 2010;1:118122.
6.Amrhein, V, Greenland, S, McShane, B.Retire statistical significance. Nature 2019; 567:305307.
7.Harrington, D.et al.New guidelines for statistical reporting in the journal. N Engl J Med 2019; 381:285286.