What really matters in hospital cleaning

A major Australian study examined cleaning processes in 11 large hospitals. Their findings are key to helping manage infection control.

For many years we have understood that a clean hospital environment is a cornerstone of infection prevention, helping to keep patients and healthcare workers safe.¹ However, environmental cleaning in hospitals is complex, and very dependent on the individuals involved, and the context in which they work.

The REACH Trial

The Researching Effective Approaches to Cleaning in Hospitals (REACH) Study² involved 11 large Australian hospitals in trialling a new cleaning bundle initiative in 2016–2017. The bundle aimed to support improved cleaning performance and reduce healthcare-associated infections (HAIs). It consisted of a set of five core evidence-based components. These were:

1. Training — We delivered training sessions to environmental services teams that included content on the impact of environmental cleaning on healthcare associated infections (HAI), cleaning roles and responsibilities, and using the REACH cleaning bundle.
2. Technique — This emphasised 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.
3. Product — This required use of a disinfectant product 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.
4. Audit — This involved monthly audit activities at the hospital using UV fluorescent marker technology, with markers applied and checked by trained site team members. Staff received individual feedback about their audit results. Summarised audit results were also provided to the environmental services teams and to clinical governance committees at the hospital.
5. Communication — This included promotional activities to raise the profile and importance of environmental services staff and the cleaning work they do. It included encouragement of daily contact between cleaning staff and ward leaders, and the representation of cleaning staff on relevant clinical governance committees.

The REACH study team worked closely with each hospital team to explore baseline cleaning practices and local context issues, and provided support to implement the bundle. Overall the study involved 6133 hospital beds and 1729 environmental services staff in six states.

Key learnings

Addressing variation

A key to the success of the trial was addressing the wide variation in hospital cleaning practices identified as part of engaging the hospital staff and understanding how cleaning “worked” in their hospital. Across the hospitals, we found variation in the type of products used, cleaning roles and responsibilities, staff communication mechanisms, the training offered to cleaning staff and cleaning monitoring processes.³

The study team spent time gathering information from environmental services staff in questionnaire and discussion group sessions to identify potential implementation issues and identify strategies to address these. We then developed a tailored plan to support the use of the cleaning bundle at each hospital. For example, all hospitals did the audit component of the bundle, but could decide who took on the auditor role and when feedback was provided to staff.

Clear roles and responsibilities

In many hospitals it was a challenge to establish exactly “who cleans what”.³ Cleaning responsibilities sometimes varied according to the type of hospital ward and, in some cases, within wards. This was further confounded in those hospitals where more than one work group had responsibilities for cleaning areas within the patient zone. Clear work instructions and documentation of cleaning roles supported use of the REACH cleaning bundle, and the associated practice change that was required.

Some work groups had responsibilities that included both cleaning and patient related duties; others had both cleaning and clinical duties.³ This often led to competing priorities for these workers. Nearly all staff recognised that their cleaning role was important for patient safety at their hospital.⁴

Communication is important

Communication mechanisms within hospitals varied. Hospitals with established staff communication pathways, for example regular staff meetings or an up-to-date noticeboard, were more easily able to engage with staff about the cleaning bundle and support practice change.

Discussion group sessions allowed environmental services staff to have input into the bundle-related activities at their hospital, for example the content of posters to support their work, and the reward and recognition strategies they wanted. Across the 11 hospitals, 223 environmental services staff took part in these sessions, with many appreciating the chance to have a say in the trial process.

The local context also had an impact on how staff viewed the REACH study and use of the cleaning bundle. At the end of the study we asked cleaners if they “felt supported by the hospital throughout the REACH trial”. Most hospitals reported high levels of support (ranging from 70% to 100%), reflecting the value of enthusiastic change champions and high levels of executive buy-in.⁴ In some hospitals this level of support sat at around 40–50%, which most likely reflects ongoing contextual and cultural issues we were unable to address, despite study team support and attempts to engage leadership.

Improving cleaning performance and infection rates

Cleaning performance improved across the hospitals, in both patient bathrooms and bedrooms. We examined the number of UV dots that were successfully removed from frequently touched points during the random audits. In bedrooms the percentage of frequently touched points cleaned improved from 64% at the start of the study to 86% at the end of the study. Bathrooms went from 55% to 76% clean. Results reinforced that some touch points, especially bed rails, tray tables and call buttons are less likely to be cleaned daily, possibly because they are in such proximity to patients.

We observed improvements in several HAIs — the biggest decrease was observed for vancomycin resistant enterococci (VRE) infections. This has important policy implications, as many hospitals are struggling with increasing rates of VRE, which has potential to have a significant burden on both patients and hospital budgets. Organisms such as VRE also have potential to spread easily in aged and residential care facilities, meaning that an increased focus on cleaning in these settings may be warranted.

Investing in cleaning

Our preliminary economic analyses show that the REACH bundle was a low-cost intervention. We will now complete further modelling to explore how implementing the REACH bundle would be a cost-effective way forward to continue to improve infection rates in Australian hospitals.

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. More information about the REACH study may be found here.

*Lisa Hall is Associate Professor of Epidemiology at the School of Public Health, University of Queensland (UQ).

**Alison Farrington is Research Project Manager at the Australian Centre for Health Services Innovation, Queensland University of Technology (QUT).

References:

1. Peters A, Otter J, Moldovan A, Parneix P, Voss A, Pittet D. Keeping hospitals clean and safe without breaking the bank; Summary of the Healthcare Cleaning Forum 2018 11 Medical and Health Sciences 1117 Public Health and Health Services. Antimicrobial Resistance and Infection Control. 2018;7(1).
2. Hall L, Farrington A, Mitchell BG, Barnett AG, Halton K, Allen M, et al. Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial. Implementation Science. 2016;11(1):1-10.
3. Mitchell BG, Farrington A, Allen M, Gardner A, Hall L, Barnett AG, Halton K, Page K, Dancer SJ, Riley TV, Gericke CA, Paterson DL, Graves N. Variation in hospital cleaning practice and process in Australian hospitals: A structured mapping exercise. Infection, Disease & Health. 2017;22(4):195-202.
4. Mitchell BG, White N, Farrington A, Allen M, Page K, Gardner A, et al. Changes in knowledge and attitudes of hospital environmental services staff: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study. American Journal of Infection Control.

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