Investing in hospital cleaning for infection prevention
Environmental cleaning plays an important role in preventing healthcare-associated infections and, in turn, delivers cost savings for hospitals.
Healthcare-associated infections are a significant patient safety risk and are costly to treat. In Australia, there are an estimated 165,000 infections each year[1]. Environmental cleaning plays an important role in preventing healthcare-associated infections. However, little is known about the impact of better cleaning practices on infection rates, and whether additional investment in environment cleaning for this purpose is justified.
To generate evidence for the value of environmental cleaning, the Researching Effective Approaches to Cleaning in Hospitals (REACH) trial implemented an evidence-based cleaning intervention in 11 Australian hospitals. The intervention was a cleaning ‘bundle’ that comprised five components: training, technique, product, audit and communication[2].
At the start of the study, differences in existing cleaning practices and processes were identified between participating hospitals [3]. This meant that the cleaning bundle could be tailored to meet local hospital needs. All 11 hospitals implemented the intervention, between 20 and 50 weeks. The analysis of trial outcomes was published earlier this year, which showed that the cleaning bundle improved cleaning performance in patient bedroom and bathroom areas and reduced healthcare-associated Staphylococcus aureus bacteraemia (SAB) and vancomycin-resistant enterococci (VRE) infection rates [4].
These findings showed the value of the trial on clinical outcomes, but we also wanted to evaluate whether the REACH cleaning bundle was a cost-effective intervention. To address this question, we compared the cost of implementing the cleaning bundle in all 11 hospitals with expected economic returns from fewer SAB and VRE infections [5]. The aim of our analysis was to provide information to hospital decision-makers on the decision to adopt the cleaning bundle as part of their hospital’s infection prevention and control program, as a valuable use of scarce healthcare resources.
The costs of improving hospital cleaning
We collected detailed information from all hospitals about costs incurred from establishing and maintaining the cleaning bundle during the trial. Examples of costs included the purchase of supplies, changes in product use and time commitments from hospital staff as part of their current workloads. Dollar values were assigned to staff time and consumables to provide a realistic estimate of the cost of implementing the bundle alongside existing hospital initiatives.
Total costs varied between hospitals, which was driven by multiple factors, including hospital size, the number of cleaning staff employed and the number of weeks spent implementing the bundle. Analysis of these data showed that the bundle was a low cost intervention, costing $349,000 for all 11 hospitals combined, or approximately $2500 for every 10,000 patient bed days affected by the intervention.
The economic case for investing in infection prevention
There is a strong economic case for hospitals to invest in measures that prevent healthcare-associated infections [6]. Patients who acquire an infection while in hospital require additional treatment with antibiotics, are likely to have longer length of stay and are more likely to die compared with non-infected patients. Investing in measures that prevent infections can therefore save hospital resources for other uses and maximise health benefits for at-risk patients.
Our cost-effectiveness analysis therefore considered the potential cost savings from fewer infections under the cleaning bundle, as well as health benefits gained from fewer infection-related deaths. We consulted infectious diseases experts on the costs of treating SAB and VRE infections, and gathered evidence from the literature on expected patient outcomes due to infection. Patient health benefits were measured in quality-adjusted life years (QALYs), which represented years of life gained among patients who would have died from infection if the cleaning bundle was not implemented, adjusted for perceived health-related quality of life.
Lower infection rates observed from the REACH trial equated to the prevention of infection (SAB and VRE). Preventing these infections generated approximately $147,000 in cost savings over the trial (62 weeks). Approximately two-thirds of cost savings were attributed to the release of hospital bed days from fewer infections. When combined with implementation costs and estimated health benefits, our analysis showed that adopting the bundle had more than an 80% chance of being cost-effective, at an incremental cost of $4684 per QALY. This result corresponded to a net economic value of approximately $1 million in health benefits after accounting for implementation costs.
The results of our analysis provide strong evidence to support the allocation of hospital resources towards improving environmental cleaning practices. By implementing and evaluating the REACH cleaning bundle in a representative mix of Australian hospitals, we have provided decision-makers with information on the real-world costs of implementation and the cost-effectiveness of the cleaning bundle as an evidence-based strategy for reducing the burden of healthcare-associated infections.
The REACH study was funded by an NHMRC Partnership project grant GNT1076006, led by Queensland University of Technology and Wesley Medical Research. Industry partners were Ecolab, Kimberly-Clark Professional and Whiteley Corporation, who provided resources to support data collection.
References
- Mitchell BG, Shaban RZ, MacBeth D, Wood C-J, Russo PLJI, Disease, Health. The burden of healthcare-associated infection in Australian hospitals: a systematic review of the literature. 2017; 22(3): 117-28.
- Hall L, Farrington A, Mitchell BG, et al. Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial. Implement Sci 2016; 11: 44.
- Mitchell BG, Farrington A, Allen M, et al. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infect Dis Health 2017; 22: 195-202.
- Mitchell B, Hall L, White N, et al. An environmental cleaning bundle to reduce healthcare-associated infection rates in hospitals: a randomized clinical trial. Lancet Infectious Diseases 2019; 19(4): 410-8.
- White NM, Barnett AG, Hall L, et al. Cost-effectiveness of an environmental cleaning bundle for reducing healthcare associated infections. 2019.
- Graves N. Economics and preventing hospital-acquired infection. Emerg Infect Dis 2004; 10(4): 561-6.
About REACH
- 11 hospitals recruited from six states.
- Involved 6133 hospital beds and 1729 environmental services staff.
- Primary outcome: Weekly confirmed cases of healthcare-associated Staphylococcus aureus bacteraemia (SAB), Clostridium difficile infection (CDI) and vancomycin-resistant infection (VRE).
Components of the REACH cleaning bundle:
Training sessions delivered to environmental services teams including content on the impact of environmental cleaning on healthcare associated infections (HAI), cleaning roles and responsibilities and using the cleaning bundle.
Attention paid to cleaning technique, including the importance of a defined and consistent cleaning sequence, daily cleaning of the high-risk frequent-touch points and the use of sufficient pressure and movement.
Required use of disinfectant for all discharge cleans and for daily cleans of high-risk/precautions rooms; use of detergent for routine cleans; use of point-of-care wipes for medical equipment; and adherence to manufacturers’ instructions for product use.
Monthly auditing of selected hospital rooms using UV fluorescent marker technology. Regular audit feedback was provided to environmental services teams and to clinical governance committees at each hospital.
Promotional activities to highlight the role and importance of environmental services staff. Activities encouraged daily contact between cleaning staff and ward leaders or managers and cleaning staff representation on relevant clinical governance committees.
Cleaning staff and hospital bed numbers
6133 hospital beds
1729 hospital staff
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