Environmental contamination and cleaning practices in long-term care: a transdisciplinary mixed-methods study

Abstract Objective: To identify system-level barriers to effective environmental cleaning and disinfection in long-term care (LTC) facilities. Design: Transdisciplinary, mixed-methods approach using human factors engineering and environmental sampling to assess environmental cleaning practices and associated multi-drug resistant organism (MDRO) burden in LTC patient rooms and common areas. Setting: Two high-acuity skilled nursing facilities in Maryland. Methods: Environmental sampling of high-touch surfaces (HTSs) was performed in resident rooms, communal areas, and nursing stations. Samples were analyzed for MDROs and overall bacterial burden. System-level barriers were assessed through observations of cleaning and focus groups with environmental services (EVS) staff and supervisors, guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Results: Of 123 composite samples of environmental surfaces, 76% of patient room samples were culture positive for 1+ MDRO, with MRSA the most prevalent organism. Quantitative bacterial burden was higher from Composite 1 (the area in the room closest to the resident) than any other composite in the resident room (median of 27.17 CFU/mL/cm 2 vs 4.55 (near door) and 1.22 (bathroom)). Observations indicated significant deviations from cleaning protocols, with only 43% of HTSs cleaned per facility policy. Focus group discussions highlighted systemic challenges, including inconsistent training, frequent interruptions, and poor communication among staff. Conclusions: The findings underscore the burden of MDRO contamination in LTC settings and critical barriers to effective environmental cleaning. Addressing these issues through standardized training with feedback mechanisms, enhanced communication, and leadership engagement is essential for improving infection prevention efforts and resident safety in LTC facilities.