How clean is your hospital?

Environmental hygiene has re-emerged as a key component of infection prevention strategies over the past few years as healthcare providers have striven to reduce infections caused by Clostridium difficile, however challenges in providing and demonstrating an effective cleaning strategy and service remain. One challenge is that the provision of assurance that cleaning has been effective (or even done at all) is often still reliant on the human eye. Is this enough or are there more quantifiable methods available? The other significant challenges that confront healthcare providers are that trained housekeeping staff are not solely responsible for carrying out all cleaning functions; divisions in responsibilities remain and nurses frequently undertake some of these cleaning tasks and not just relating to clinical equipment. Yet are nurses prepared and trained to do this in a competent manner? This article seeks to highlight opportunities for improving cleaning standards and to briefly describe methods of providing assurance to organisations that cleaning standards are being met for all items that patients may come into contact with as we continue to strive to reduce avoidable infections. It is often stated that contaminated hands of healthcare staff most frequently transmit healthcare-associated pathogens. Potentially harmful organisms found on hands are mostly transient and are acquired after contact with patients and their environments. Thus, environmental contamination is a key contributor to the spread of healthcare-associated pathogens and organisations providing care for the vulnerable should ensure that environmental hygiene is a critical component of their infection control strategies (Carling and Bartley 2010, Weber and Rutala 2013). As highlighted in a recent review paper (Donskey 2013) the evidence base demonstrating the role of the environment has steadily grown, rebutting a review of the literature undertaken ten years previously that found no evidence of the role of the environment (Dettenkofer, Wenzler et al. 2004).

Assurance of effectiveness of cleaning

Given that organisations expend a significant outlay on cleaning, how is assurance that it has been effective provided? Methods for monitoring cleaning procedures include visual assessment, application of invisible fluorescent marks with checking for presence of the marker after cleaning has taken place, microbiological methods by measurement of aerobic colony counts and detection of residual adenosine triphosphate (ATP). ATP is present in organic matter (including micro-organisms, food and human body substances) and has been used extensively in food manufacturing for some time to assess the efficiency of hygiene. It is not possible to use time spent cleaning as a surrogate for thoroughness of work carried out. In another recent research paper (Rupp, Adler et al. 2013), the time spent cleaning a hospital room showed no correlation between time spent in cleaning a room and the effectiveness of cleaning in terms of surfaces cleaned. In fact some whole rooms cleaned in 18 minutes attained 80% of surfaces cleaned whereas rooms in which over an hour was spent achieved only cleanliness of 20% of surfaces. ATP measurement has the advantage of being able to provide instant feedback on cleaning performance as opposed to the 24-48 hours required to obtain results using conventional laboratory methods where growth of organisms is required. Readings from the ATP equipment provide a useful source of data that can enable monitoring of the sufficiency of cleaning over time (Boyce, Havill et al. 2009). Fluorescent marking of surfaces is new to the UK, however a number of papers from the US have been published that indicate the potential for this as a monitoring tool (Carling, Briggs et al. 2006). Surfaces are marked with an invisible water-soluble marker and then checked for residual dye once cleaning has taken place. Which of these methods is the most useful? A recent study has demonstrated that quantitative methods of assessing cleanliness are far superior to reliance on visual methods and are comparable with microbiological methods, which are considered to be the gold standard (Luick, Thompson et al. 2013). This study undertook simultaneous assessment of surfaces after environmental cleaning using an invisible fluorescent marker, ATP and visual checks and compared them with aerobic colony counts. Both ATP and the fluorescent marker provided a high positive predictive value (90%) and the visual check had a PPV of just 9%. The negative predictive values were comparable. Thus, two methods of providing quantitative assurance of effectiveness of cleaning are available to organisations. These methods are surely the future of robust monitoring of cleanliness of healthcare facilities.