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.

When are hospitals cleaned?

The type and frequency of routine cleaning depend upon clinical risk, patient turnover, the 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.

• Adams C, Smith J, Dancer SJ. “Examining the relationship between surface bioburden and frequently touched sites in the healthcare environment”. Report in preparation, 2016.
• Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clin Microbiol Rev. 2014 Oct;27(4):665-90.
• Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces?. A systematic review. BMC Infect Dis. 2006 Aug 16; 6:130.
• Sattar SA. Promises and pitfalls of recent advances in chemical means of preventing the spread of nosocomial infections by environmental surfaces. Am J Infect Control. 2010 Jun;38(5 Suppl 1):S34-40.
• Carling PC, Parry MF, Von Beheren SM, Healthcare Environmental Hygiene Study Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008 Jan;29(1):1-7.
• Bogusz A, Stewart M, Hunter J, Yip B, Reid D, Robertson C, et al. How quickly do hospital surfaces become contaminated after detergent cleaning?. Healthcare Infection. 2013 Feb 27;18(1):3-9.
• Balm M, Jureen R, Teo C, Yeoh AEJ, Lin RTP, Dancer SJ, et al. Hot and steamy; fatal outbreak of Bacillus cereus in Singapore associated with construction work and laundry practices. J Hosp Infect. 2012 Aug;81(4):224-30.
• Dancer SJ, Humphreys H, Carling P. Disinfection is not the same as cleaning. Crit Care Med. 2011 Jul;39(7):1853; author reply 1853-4.
• Dancer SJ. Hospital Cleaning in the 21st Century. Eur J Clin Microbiol Infect Dis. 2011 Dec;30(12):1473-81
• Anderson RE, Young V, Stewart M, Robertson C, Dancer SJ. Cleanliness audit of clinical surfaces and equipment: who cleans what?. J Hosp Infect. 2011 Jul;78(3):178-81.
• Mulvey D, Redding P, Robertson C, Woodall C, Kingsmore P, Bedwell D, et al. Finding a benchmark for monitoring hospital cleanliness. J Hosp Infect. 2011 Jan;77(1):25-30.
• Dancer SJ, White L, Lamb J, Girvan EK, Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Med. 2009 Jun 8;7:28.
• Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. J Hosp Infect. 2009 Dec;73(4):378-85.
• White L, Dancer SJ, Robertson C, MacDonald J. Are hygiene standards useful in assessing infection risk?. Am J Infect Control. 2008 Jun;36(5):381-4
• Dancer SJ, White L, Robertson C. Monitoring environmental cleanliness on two surgical wards. Int J Environ Health Res. 2008 Oct;18(5):357-64.
• Dancer SJ. Importance of the environment in MRSA acquisition: the case for hospital cleaning. Lancet Infect Dis. 2008 Feb;8(2):101-13.
• Dancer SJ. How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in hospitals. J Hosp Infect. 2004 Jan;56(1):10-5.
• Dancer S J. Mopping up Hospital Infection. J Hosp Infect. 1999 Oct;43(2):85-100.

FEM Contributors

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

Other contributors

• dancers
• Vladimir Prikazsky