INFECTION CONTROL “Superbugs continue to emerge,
but there are no more antibiotics,” Martin Easter warned. “However, cleaning is a key component of infection prevention – it reduces the reservoir of pathogens and breaks the chain of cross infection.” He went on to explain that decontamination requires both effective cleaning and disinfection. Unfortunately, users do not always understand or differentiate between these two completely different processes. In addition, cleaning is often considered of lesser importance. It is given little support and attention; and is viewed as low skilled and burdensome on-cost. Around 90% of this cost is attributed to labour. Furthermore, it is delivered inconsistently and is often inadequately measured, which is a wasted resource and potential hazard. “What other process is there, in
healthcare, that has such an impact on health and infection, yet is so undervalued?” commented Martin Easter.
What and how do we measure? He went on to point out that too many Trusts rely on visual assessment of cleanliness, which is subjective and unreliable. Carling and Bartley (2010)2 highlighted that 89% of hospitals use visual assessment of cleaning but this can only detect gross lapses in practice. They evidenced that only 34%-40% of surfaces are actually cleaned in accordance with hospital policies. However, monitoring and interventions improve the thoroughness of cleaning from 40% to 82%. Unfortunately, a variety of guidance documents have missed the opportunity to highlight the need for objective methods of monitoring cleaning performance. The BSI document, Specification for the planning, application and measurement of cleanliness services in hospitals (PAS 5748)3
, for example,
focuses on visual assessment, according to Martin Easter, yet this can only provide an aesthetic assessment. There is a need for an objective measure of cleanliness, performance and risk, he asserted. “If you want to know how well
The management and auditing of cleaning is important from the perspective of infection prevention and patient satisfaction, as well as in terms of managing costs.
22 THE CLINICAL SERVICES JOURNAL
Only 34%-40% of surfaces are actually cleaned in accordance with hospital policies. However, monitoring and interventions improve the thoroughness of cleaning from 40% to 82%.
cleaning is performed, you need to be able to measure it,” said Martin Easter. Setting the agenda for the rest of the symposium, he concluded with a quote by H. James Harrington4
: “Measurement is the first
step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”
Why and how to assess hospital cleanliness Professor Chris Griffith, Emeritus professor, Cardiff School of Health Sciences, went on to provide a detailed insight into: ‘Why and how to assess hospital cleanliness’. Prof Griffith illustrated that opinion on the importance of cleaning has shifted over the years. During Florence Nightingale’s era, it was viewed as extremely important, but, by the late 1970s and 80s, the environment came to be viewed as less important in terms of the spread of hospital infection. Opinion has now come full circle and a number of papers by Galvin et al (2012)5
, Otter et al (2011)6 (2006)7 and Drees et al (2008)8
, Hardy et al have all
highlighted considerable evidence linking the acquisition of nosocomial pathogens and their presence on hospital surfaces. The management and auditing of cleaning is important from the perspective of infection prevention and patient satisfaction, as well as in terms of managing cleaning costs, he commented. Hospital spending on cleaning has significantly increased, over recent years, with additional funds allocated during the Government’s ‘deep cleaning’ initiative. However, there is also significant variation between hospitals in terms of the budget spent on cleaning. He presented figures which showed that some Trusts with very high spending on cleaning perform worse on infection rates, compared to other Trusts that spend less. If hospitals do not measure the effectiveness of cleaning, they risk wasting time and money. Therefore, they need to ask how cleaning can be best managed, while saving money, as well as lives, he asserted. Prof Griffith pointed out that over 50% of care worker non compliance is due to a poor management culture (Griffith, 2010).9 To ensure effective management of cleaning, a cleaning policy needs to be developed, incorporating cleaning
schedules and record forms. Cleanliness needs to be benchmarked and an environmental test strategy needs to be devised. Cleaning then needs to be monitored and evaluated using audit and trend analysis, and this requires some form of testing. Prof Griffith supported the opinion that
‘the key to quality is reducing variation’ and emphasised the key role of measurement. Ultimately, it is important to be able to set standards to ensure a scientific approach to environmental cleaning. Testing has further benefits, he pointed out: it helps to identify sources of contamination and difficult to clean areas; it evaluates the ‘cleanability’ of surfaces and equipment, as well as assisting in determining cleaning frequency and the evaluation of new cleaning techniques. However, he added that ‘no amount of testing will in itself give you clean surfaces.’ The real value of testing is to inform you about the effectiveness of the cleaning process, how well it is managed and to identify areas for improvement. (Griffith, 2008)10 Prof Griffith highlighted the fact that
the Epic 2 Guidelines state that: “The hospital environment must be visibly clean and free from dust and soilage and acceptable to patients, their visitors and staff.” (Epic 2 Guidelines, 2007)11 However, he stressed that “In isolation, visual assessment is not a good indicator of surface cleanliness.” (Griffith, 2005)12 He went on to highlight the need for effective auditing, as audits are often performed ‘haphazardly’ by infection and control teams due to a lack of experience and formal training, as well as a lack of resources, time and appropriate tools. (Hay, 2006)13
How clean are hospital surfaces? In 2000, Griffith et al reported findings from a four-part study assessing cleanliness in up to 113 environmental surfaces in an operating theatre and a hospital ward. Surfaces were assessed visually, then by using microbiological methods and ATP bioluminescence.14 Using microbiological and ATP specifications, around 76% of sites were found to be unacceptable after cleaning. Visual assessment was a poor indicator of cleaning efficacy with only 18% considered unacceptable. Sites most likely to fail in the ward were in the toilet and
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