DECONTAMINATION
an infection from the prior room occupant (as high as 71%, if the prior patient had A. baumannii). In addition, a prospective cohort study in an ICU, by Nseir et al (2011),5
also found that successive occupiers of a room are at risk from organisms from previous occupants. Quality audits showed that 56% of rooms were not cleaned correctly – failures were highest for door handles (45%), monitor screens (27%) and bedside tables (16%).
Cleaning is vital and yet it is either carried out by low paid staff of low status who have been trained, or well-paid staff of higher status, who have not been trained. Garvey pointed out that a longer clean is not necessarily a more effective clean, while systems to monitor cleaning are often ineffective or absent.
“When healthcare practitioners undertake their degrees, how much training do they have around cleaning and its importance – particularly around the science and the reasons why we do what we do?” he commented. “Cleaning is a science and we’re trying to get people’s attention. But how much do we teach people on the fundamentals?”
When there are outbreaks, there is a tendency to shift the responsibility onto facilities and, in general, there is confusion over the division of labour. To tackle this confusion, a schematic of the categories of cleaning has been developed at University Hospitals Birmingham – from green, amber and red cleans, through to platinum and violet cleans – depending on the infectious status and pathogens involved. Green cleans, for example, are
performed by clinical/ward staff using Clinell wipes, following the discharge of patients (with no known infection and no diarrhoea); platinum cleans are carried out by facilities, following the discharge of patients with Carbapenemase Producing Enterobacteriaceae (CPE) or multi-drug resistant Acinetobacter, and involve a steam clean, Chlor-cleaning, HPV misting and curtain change. Violet cleans are also
Mark Garvey, speaking at the CSC annual scientific meeting, called for cleaning to be viewed as a science and to tackle confusion over the division of labour.
performed by facilities and involve Chlor- cleaning and curtain changes but use a UV-machine in areas where HPV cannot be used. Pre-cleaning, prior to amber, red, platimum and violet cleans, is performed by the clinical/ward staff. Garvey commented that, over recent years, wipes have become firmly established in clinical areas in the UK and other countries. They are used on patients, equipment (from nasendoscopes to commodes), and the environment for cleaning and/or disinfection. The advantages are they are convenient and can be placed at the point of care and they are pre-mixed and pre-measured.
Birmingham previously used a two-stage wipe and instructed nursing staff to use the detergent clean, followed by the disinfection clean.
“When we actually went on to the wards and looked at this, most people would just use the disinfection wipe as the alcohol smelt more potent. However, this fixes things to the surface,” Garvey explained. “Often, staff were not using the detergent wipe. So, we moved to the single-stage Clinell wipes, which contain a surfactant that is good for cleaning. They also contain a disinfectant. When we moved to the one-wipe system, we saw a significant reduction in MRSA acquisition.” (Garvey et al, 2018)6
This was due to the fact that the system made cleaning much easier for staff. Garvey explained that funding was obtained to take samples to identify microorganisms with the Medical Assessment Unit (MAU) and to examine the cleaning protocols. Environmental samples were taken by swabbing seven high-touch sites, such as the bed rail, patient armchair, patient chair seat, patient table (overside and underside), patient locker and nurse call button. The study looked at the total viable counts before and after cleans. The key take-home message was that the actual physical (green) clean, using Clinell wipes, achieved a significant log reduction in microorganisms in the environment, when
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performed properly. However, green cleans were often missed. “The first clean is vitally important. HPV and UV won’t work unless you do a good physical clean in the first instance,” he commented. He explained that the study initially found C.difficile in the MAU environment; after the green clean, it could no longer be found. Garvey suggested that this was due to the physical removal of the spores. However, an important aspect was also the education provided – when education stopped, C.difficile increased; when it was re-started, it went back down. Garvey went on to highlight an analysis of a randomised controlled trial (RCT) by Anderson et al (2017)7
which assessed
four different strategies for terminal room disinfection. The study found that enhanced terminal room cleaning with UV in high-risk rooms led to a decrease in hospital-wide incidence of C.difficile and VRE. “UV is very effective and is very quick as well,” Garvey commented, adding that it won’t be effective if the room is cluttered with lots of equipment, however, as this will create shadows.
University Hospitals Birmingham sought to tackle VRE on its ITU and liver wards, following some outbreaks, which prompted the purchase of a UV machine. Since the introduction, levels have plummeted. He went on to highlight a paper, which
looked at Pseudomonas aeruginosa infection in augmented care areas, in four large UK hospitals (Halstead et al, 2021).8 Over a 16-week period, all water outlets in augmented care units of four hospitals were sampled for Pseudomonas aeruginosa (P. aeruginosa) and clinical isolates were collected. The outlet and clinical isolates underwent whole-genome sequencing (WGS). Outlets were positive in each hospital and there were 51 persistently positive outlets in total. WGS identified likely transmission from outlets to patients in three hospitals for P. aeruginosa positive patients. Approximately 5% of patients in the study
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