By Michael Rollins, Consultant Environmental Infection Prevention Specialist, UK
Associate: Hahdat Al Tamyuz, Abu Dhabi, UAE

Why is this an important issue we cannot afford to ignore?
Cleaning, whilst recognised as an essential service, has not received the necessary investment in staff education, training, technical skills and material resources essential to keep pace with the dynamic complexity of the patient environment and the Infection Prevention and Control challenges presented to maintain Healthcare Environment Patient Safety.

Can we expect poorly trained staff to understand a problem they cannot see?
Through investment in hygiene education, competency based technical training and rapid audit tools we can help to make the invisible visible.

Environmental support services often operate independently as an outsourced service and are not fully integrated within the risk management scope of the IPC Guidelines. A situation which typically results in inconsistent environmental services (EVS) practices, standards and outcomes.

Over the past 10 years, there has been a growing body of evidence which has clearly established that an unclean environment can support a high bio-burden of micro-organisms on frequently touched environmental surfaces. In the absence of robust hygiene practice these surfaces present a significant risk and cause of preventable healthcare associated infections.  

Additionally, there is growing concern over the increase in Multi-Drug Resistant Organisms (MDRO) and prevalence of infections particularly due to MRSA, VRE, CRE Pseudomonas aeruginisa and Acinetobacter Baumannii. Contamination is further complicated by the difficulty of eradication of these organisms from the variety of surface materials found in modern healthcare equipment.

Not all surfaces react the same in terms of ‘cleanability’ and efficacy of disinfectants can be compromised by the inherent surface characteristics and equipment design. In many cases, we are no longer cleaning a flat smooth surface but rather a three-dimensional profile, which harbours residue and inhibits removal by traditional cleaning methods. The design of the cleaning tools, technique and frequency of cleaning are all critical factors in achieving successful decontamination and maintaining a safe clean environment.

Microorganisms associated with nosocomial infection can remain viable for long periods of time (days to months) within the patient environment.  Studies have evidenced the acquisition of MDRO infections from prior patient room occupants as a result of sub-optimal cleaning and decontamination.

The process of cleaning physically removes soil and microbial contamination. Disinfection eradicates viable pathogens from the contact surface. However, disinfectants alone are not sufficient. The disinfection process must be preceded by mechanical action (cleaning) to cut through the microbes’ protective barrier (biofilm) to allow direct contact and chemical disinfection to take place.  

Environmental surfaces, which are clean and dry, will not support microbial colonisation. 

There is a direct correlation between the cleanliness of the patient environment (bio-burden) and commensurate level of contamination of healthcare workers hands. Contaminated hands are acknowledged as the principle cause of preventable nosocomial infection. 

Visible cleanliness is an important factor in patients’ impression and confidence of quality of care. However, from a patient safety management perspective, visual monitoring does not necessarily correlate with microbiological risk. Making the invisible microbial challenge ‘visible’ through EVS staff education, rapid detection audit tools and evidence-based Standard Operating Procedures (SOPs) provides the means for a front-line high-impact intervention in infection prevention and control.

Lessons learned from Environmental Research and guidelines for practical implementation of quality improvement interventions

Hospital cleanliness and sub-optimal cleaning performance and frequency of cleaning has been linked with the incidence of healthcare associated infection.

• Webber et al attributes 20-40% of HAI to cross-contamination via healthcare worker (HCW) hands.
• Huang et al identified that patients admitted to a room formerly occupied by an infected patient are at increased risk of acquiring the same organism, suggesting that terminal cleaning practices can be inadequate with patients acquiring the organism directly from contaminated surfaces or indirectly through healthcare workers who contaminate their hands within the patient environment.
• Multiple studies highlight the potential for indirect cross-contamination of HCW hands from contact with hospital surfaces. In some cases the extent of patient-to-patient transmission has been found to be directly proportional to the level of environmental contamination. The implications for high-risk environments such as the ICU are significant due to the large number of patient contacts. (Wilson et al: Mean 21 per hour; Range 9-42 per hour).
• A prospective multi-centre study, Carling et al, defined high-risk objects in patient rooms marked with UV marker prior to cleaning. Overall 49% of objects/surfaces were not cleaned; (Range 35-81%). Results illustrated a wide variation in cleaning performance and the need for validation of cleaning methods and standardisation of operating procedures.
• Research into the efficacy of traditional cleaning practices has identified the significant variability of decontamination performance on the variety of types of environmental surfaces found within the patient environment and their condition (surface deterioration and porosity over time).
• Practical cleaning effectiveness studies have revealed the variable affinity of microorganisms to surface type and their resistance to disinfection and/or physical removal from these surfaces. Critically, many of these same surfaces are the same high-contact hand touch points responsible for cross-contamination to healthcare worker’s hands.
• Wilson et al identified the rate of gross contamination of frequently touched surfaces such as clinical equipment, patient monitors, bed rails, IV poles, keyboards, etc can be three hours or less. The frequency of scheduled cleaning of these same surfaces is typically twice a day resulting in obvious implications of cross-contamination and infection risk. Further study of cross contamination potential from hand contact with patient bed rails illustrated transfer efficacy of up to 60% with subsequent contamination of consecutively touched surfaces.

Numerous research studies have been published evaluating the efficacy of individual cleaning technologies (microfiber textiles, dry steam vapour, ultrasonic immersion), disinfectant chemistries and methods of no-touch area decontamination (Hydrogen peroxide vapour, UVC irradiation). Recent studies have evaluated the ‘cleanability’ and variances in characteristics of material surfaces found within the patient environment. This research is invaluable in better understanding the physiology of individual pathogens and their characteristics of adherence and transfer to and from surfaces and hands; presenting a case for further investigation into topographical modification of material surfaces to standardise ‘cleanability’ and predictable outcome of cleaning/disinfection procedures.

Who cleans what, when and with what frequency?

The introduction of more sophisticated medical and patient-centred equipment incorporating multiple materials in their manufacture; including integrated electronics, sensors and digital components into their exposed surfaces, presents a significant challenge to determining and adopting hygiene best practice.

Who cleans what? Many items fall under the responsibility of the nursing staff. But their priority is patient care and the frequency of cleaning by nurses is evidenced to be inadequate to maintain clean safe surfaces. A confounding issue is the availability to nursing staff of suitable cleaning materials. Typically these are impregnated wipes which research has shown to deliver inconsistent results. This issue is currently under review in the U.K. in line with new ISO test standards introduced.

The divide between environmental services and nursing staff with shared responsibility as to who cleans what, when and how often remains an operational, and in some cases, a cultural barrier to successful implementation of quality improvement initiatives and optimal use of resources.
The argument can be made that nurses and healthcare assistants are trained to provide clinical patient care, while suitably trained ‘Patient Environment Hygienists’, utilising evidence-based enhanced cleaning and decontamination technologies can provide clean and safe patient environments.

The Debate: EVS competency based training and certification of ‘hygienists’ – a standard requirement and qualification for healthcare cleaning contractors

The healthcare environment is complex and dynamic and requires a systematic approach to environmental hygiene practice commensurate with patient-centred risk factors. Intensive care, high dependency units, oncology, haematology, surgical, infectious diseases are all examples of high-risk patient environments each requiring a specific approach to environmental hygiene practice.

Hospital cleaning contracts should incorporate the need for qualified ‘hygienists’ and support the investment in continual professional development and practical training in emerging hygiene technologies. Contractor performance should be measured as a quality output. This includes greater coordination and collaboration with commercial suppliers and IPC to determine training of Standard Operating Procedures for supplied equipment.

The successful integration of infection control, IPC link nurses and environmental support services should be based on the clear understanding of the environmental risk factors associated with the patient and ward environment profile.

Contracted EVS staff turnover is a risk factor in achieving sustained competency and quality performance. The implication for training and quality improvement is the need and investment for structured and continued staff development. Cleaning staff should be trained specifically for their area of deployment and transfer between wards and departments avoided. This principle not only supports consistency and efficiency, but also importantly, builds rapport, cooperation and trust between healthcare workers and EVS staff, recognising cleaning staff as a valued member of the ward team and contributor to patient safety.

In practical terms, quality improvement in environmental hygiene is a progressive process that must first establish the baseline as to where you are now and from this point develop a coordinated plan with clearly defined goals, milestones and support mechanism.
Feedback to staff is a critical success factor. Human nature resists change. Supervision of trained practice until embedded prevents slippage and underpins long-term sustainability of the quality improvement activity.

Conclusion
Environmental support services staff is typically an under-utilised and latent high-impact resource in the quest for quality improvement and patient safety.
Hospital management should recognise the importance of this resource not only as a service facility but also as a productive participant and contributor to patient safety.
This requires the redefining of roles, responsibilities and values and elimination of the mop and bucket cleaning culture in favour of developing the resource of an integrated team of professional patient environment hygiene specialist technicians.

A methodical and strategic approach to environmental hygiene and disinfection has the potential to reduce healthcare associated infection and reduce the incidence and severity of infection outbreaks.

The investment cost in staff, training and hygiene technology is minimal when compared to the financial impact of treatment of HAIs, extended bed occupancy, loss of revenue. Notwithstanding patient pain, suffering and mortality as a result of preventable infection.

The new generation of enhanced cleaning and disinfection technologies have been evidenced to be effective in the reduction of bio-burden within the patient environment. These technologies, including rapid detection bio-luminescence and UV audit and monitoring tools, anti-microbial surfaces, topical surface modifying treatments and automated area decontamination are all technologies available to EVS and present an invaluable resource within the arsenal of infection prevention and high-impact interventions in the prevention of healthcare associated infection.

Michael Rollins is a Speaker at the Infection Control Conference held as part of Patient Safety Exhibition in Dubai, UAE, on 26th October, 2017.