A new randomised controlled intervention study published in the Lancet Infectious Diseases by Professor Brett Mitchell and a group of Australia researchers reports that introducing an environmental cleaning bundle reduced the rate of HCAI.
The study was a powerful randomised controlled trial performed in 11 Australian hospitals. The cleaning bundle was a multimodal intervention, focusing on optimising product use, cleaning technique, staff training, auditing and feedback, and communication. The bundle was aimed at improving both routine daily cleaning and cleaning/disinfection at the time of patient discharge. The intervention did not require any new technology or tools – but was simply a reconfiguration and standardisation of approach within the existing resources allocated to cleaning in each hospital. At the start of the intervention in each hospital all cleaning staff received face-to-face training from the trial co-ordinator. This training also attempted to standardise cleaning technique. Another element of the bundle was a focus on communication, encouraging daily contact between ward leaders and cleaning staff, and board-level engagement in the cleaning process. There was also a review of the local approach to ensure that cleaning product use was optimised.
The impact of the cleaning bundle was measured by reviewing rates of key HCAI, and also by monitoring the removal of fluorescent markers from key sites in patient rooms and bathrooms. The rate of VRE identified in sterile infections reduced significantly by 37% following the implementation of the bundle. The rate of C. difficile infection and S. aureus bloodstream infection did not reduce significantly following the implementation of the bundle of interventions. It’s important to note the there was no focus on ensuring that an appropriate sporicidal disinfectant was used to tackle surfaces that could have been contaminated with C. difficile spores, so it’s perhaps not surprising to see that the rate of C. difficile was not reduced significantly. Many S. aureus bloodstream infections are 'endogenous' (where the patients themselves are the source of the infection), so less likely to be affected by an environmental intervention.
The intervention significantly improved the removal of fluorescent markers in both rooms and bathrooms. Interestingly, this continues to improve throughout the intervention period, so that 86% of marks were removed from bathrooms and 76% from rooms by the end of the intervention compared with 43% in bathrooms and 37% in rooms before the intervention. These findings reinforce that the reduced rates of HCAI were related to an improved standard of cleaning.
This study reinforces that basic steps can be taken to improve the efficacy of hospital cleaning, focussed on the training and education of staff, and that these improvements can improve patient outcomes.
Drs Stephanie Dancer and Alex Kramer, two of the biggest names in hospital cleaning and disinfection, have joined forces to write a review in the Journal of Hospital Infection, setting out four steps to clean hospitals. First LOOK, then PLAN, next CLEAN, and finally DRY.
The authors identified a gap in the literature: no articles offer a practical overview of how to clean a hospital bed space daily. So, the article aims to provide an evidence-based and ordered set of recommendations around achieving effective cleaning of a bed space.
The LOOK - The first step in the process is a visual assessment of the space to be cleaned. This needs to encompass temperature, smell, visible debris, clutter, space, lighting, patient status, and presence of clinical staff and visitors. The paper provides some helpful ‘real world’ images of how a cluttered bed space looks, and how this can impede the subsequent cleaning process.
The PLAN - Based on the visual assessment, how should the bed space be optimised for effective cleaning? This should include washing hands; re-aligning furniture, equipment and patient’s belongings for access; removal of litter, food, spillages, debris; and replenishing supplies if needed.
The CLEAN - The authors use the term 'clean' to encompass both cleaning and disinfection. This step is the 'active' step, but the other three steps are just as important in delivering an effective cleaning process. The article includes sensible advice about the rational use of disinfectants, and the use of disinfectant wipes – including advocating the GAMA ‘S’ shaped pattern for wiping (shown right).
The DRY - Perhaps the most underrated and understudied part of the process is drying. Wet surfaces introduce the risk of recontamination and biofilm formation. Therefore, surfaces should either be dried manually, or processes used that don’t require drying (such as the use of disinfectant wipes, which don’t ‘over-wet’ surfaces). This is the same principle as when decontaminating hands, where drying is a critical part of the process.
This review paper provides an evidence based 'handbook' for achieving effective cleaning and disinfection of bed spaces in hospitals. A clear focus on visual inspection of the bed space (the LOOK), careful consideration of the local application of the cleaning policies in the Trust (the PLAN), attention to the detail of the cleaning and disinfection activities themselves (the CLEAN), and not forgetting the need to leave surfaces dry afterwards (the DRY) will deliver a robust, repeatable, and effective cleaning process.
A review paper published in Clinical Microbiology and Infection discusses current trends in our understanding of C. difficile transmission. How much C. difficile infection we see is as a result of transmission within hospitals. How much is explained by acquisition of C. difficile prior to hospitalisation? Evidence is emerging and difficult to interpret, but it seems that more C. difficile infection that we once thought is caused by transmission within the community. However, a significant majority of cases are still linked to hospital transmission of C. difficile.
The Swiss review team identified 24 articles that reported on possible transmission pathways of C. difficile. Of the articles reviewed, the most commonly reported sources of C. difficile were symptomatic carriers
(53%), the hospital environment (40%), and asymptomatic carriers (20%). The single most common
hospital-based environmental reservoir of C. difficile was, unsurprisingly, in the rooms of affected patients – accounting for 25% of environmental sources. However, the majority of environmental sources were actually outside of the rooms of C. difficile patients. Therefore, one of the authors’ conclusions is to extend environmental strategies beyond the rooms or clinical spaces used to care for patients with known C. difficile. This means considering extending the use of sporicidal disinfectants, especially for toilets, bathrooms, and spaces dedicated to cleaning (such as utility rooms) – together accounting for 50% of environmental sources of C. difficile.
In the community setting, contact with symptomatic and asymptomatic carriers (including infants) was the source for 30% of cases, contact with residents of long-term care facilities accounted for 30%,
and contact with environmental surfaces accounted for 20%. As in healthcare settings, the findings of this study suggest that extending the use of sporicidal disinfectants may be helpful in preventing
C. difficile transmission in community settings.
The advent of whole genome sequencing has provided new insight into the transmission of C. difficile. However, it is difficult to be certain of C. difficile transmission routes in any setting. This review does a good job of navigating and simplifying a complex issue to provide some simple concluding recommendations: to focus on extending disinfection procedures beyond the immediate surroundings of symptomatic carriers in healthcare settings and to target household members and long-term care residents in the community.