Hospital cleaning and decontamination

Introduction

There is increasing interest in the role of cleaning in controlling hospital-acquired infections (HAIs). Pathogens include meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), norovirus, multi-resistant Gram-negative bacilli and Clostridium difficile, persist in the healthcare environment for considerable lengths of time. Both detergent and/or disinfectant-based cleaning can control these pathogens in routine and outbreak situations despite minimal evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including novel disinfectants, automated dispersal systems, steam cleaning and a range of antimicrobial surfaces and coatings. These methods are difficult to evaluate because few studies have modelled environmental data against patient outcome. This means that current decontamination practices cannot be assessed for cost-effectiveness. Indeed, recent studies report the value of physical soil removal using detergent compared with more expensive (potentially toxic) disinfectant-based methods. Clearly, more work is required on cleaning and decontamination in hospitals, particularly with escalating antimicrobial resistance. Cleaning practices should be tailored to clinical risk, location, site and hand-touch frequency and evaluated for cost-benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces will supplement infection prevention strategies for healthcare environments, including those targeting multi-drug resistant pathogens. The following section contains the definitions of cleaning and decontamination; the justification for adequate healthcare decontamination; description of methods for routine (daily) cleaning; cleaning following patient discharge; cleaning of rooms housing infected patients; cleaning during or after an infection cluster or outbreak; automated cleaning methods: benefits and disadvantages; frequency of cleaning: high-risk areas vs low-risk areas; cleaning and decontamination hazards for staff, patients and visitors; managerial input; monitoring of the cleanliness of the healthcare environment and staff training.

Why is it important to clean hospitals properly?

Justification for hospital cleaning

The best evidence for an environmental role in pathogen transmission is provided by studies demonstrating that the risk of acquiring MRSA, VRE, Acinetobacter, Pseudomonas or C. difficile is increased if a new admission is placed in a room previously occupied by a patient colonized or infected with one of these pathogens. Such pathogens are able to survive on surfaces for days, increasing the risk of infection for patients, unless they are removed by the cleaning process. In addition, cleaning and decontamination form an important part of an outbreak control plan, although the evidence for the effect of outbreak cleaning measures is often obscured by the package of additional interventions introduced in response to the outbreak.

How are hospitals cleaned?

In hospitals, environmental surfaces are cleaned, or cleaned and disinfected, on a regular basis (e.g. hourly, daily, 3 times per week); when surfaces are visibly soiled; if there are spillages; and always after patient discharge. The type and frequency of routine cleaning depends upon clinical risk, patient turnover, intensity of people-traffic and surface characteristics. All hospitals should provide a written specification of cleaning services and their delivery for all areas of the hospital, whether provided by in-house or externally contracted staff. These should be reviewed on a regular basis by cleaning supervisors, hospital managers, estates and infection control.

Automated cleaning methods

While interventions aimed at improving cleaning thoroughness have shown improvements, many surfaces remain inadequately cleaned and therefore potentially contaminated. Unsurprisingly, several manufacturers are developing automated room disinfection units that demonstrate superior decontamination of environmental surfaces and objects. These systems use various products including germicidal light; hydrogen peroxide; steam; and ozone.

Disadvantages of automated systems

Innovative technologies obviously play a role in the environmental hygiene armamentarium, but their logistical complexity as well as costs of equipment and personnel costs make it imperative that independent, objectively controlled studies should be undertaken to clarify the true role of these technologies. Concern over the premature incorporation of these systems into routine decontamination strategies has been expressed by several authors. Cost-effectiveness studies would help aid selection from the different room decontamination systems available. Recent recommendations on innovation and research in infection control support the opportunity for hospitals to trial new cleaning and decontamination technologies and publish their findings.

Where are hospitals cleaned?

Frequent hand-touch sites such as door handles, taps, keyboards, telephones, light switches etc. are environmental surfaces that pose an increased risk of pathogen transmission. However, there is a wide range of sites and surfaces in the healthcare environment that requires cleaning, with or without disinfection, on a routine basis.

Estates premises

=When are hospitals cleaned?

The type and frequency of routine cleaning depends upon clinical risk, patient turnover, intensity of people-traffic and surface characteristics. Frequent and stringent cleaning specifications are applied to areas encompassing operating theatres, intensive care units, transplant wards and so-called “clean” rooms, where sterile medications are decanted and/or processed. Hospital kitchens, restaurants and cafes also receive targeted frequent cleaning, as do the laboratories. Less comprehensive cleaning regimens are carried out for corridors and stairwells; offices and waiting rooms; selected out-patient, general purpose and entrance areas.

Antimicrobial surfaces

Treating or coating hospital surfaces liable to contamination by pathogens could kill or inhibit microbes in order to reduce the risk of transmission to patients. Such surfaces would not necessarily obviate the need for routine cleaning but might provide a safety net for inadequate or misplaced cleaning. Self-sanitizing surfaces have the ability to supplement manual cleaning, itself dependent upon operator time, choice and ability, and thus subject to considerable variation.

References.

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==FEM Contributors

• Original contribution from Stephanie J. Dancer, Dept. of Microbiology, Hairmyres hospital, East Kilbride, Lanarkshire G75 8RG.

Other contributors

• dancers
• Vladimir Prikazsky