Better cleaning of patient rooms can reduce hospital-acquired infections

Hospitals and other healthcare settings have a choice when it comes to environmental cleaning. They can continue current patient-room cleaning practices that contribute to 100,000 fatalities yearly from hospital-acquired infections (HAIs), or they can introduce structured cleaning programs that reduce surface pathogens, reduce transmission, and reduce HAIs.

The hotel-like approach

Workers responsible for cleaning patient rooms, bathrooms, and other care areas receive little or no training in environmental hygiene, Dr. Qutaishat said during a recent webinar from Pharmacy OneSource. Cleaning supervision is haphazard and usually based on visual inspection. Few institutions have implemented structured environmental cleaning program, and even fewer validate their cleaning processes. It is, he said, a recipe for failure.

Recent studies based on environmental sampling show that appropriate levels of cleanliness and pathogen contamination are achieved on less than 40% of surfaces tested in three dozen acute-care hospitals. Structured interventions that include precise, step-by-step protocols, employee training, adequate supervision, surface testing and process validation, and regular data collection and analysis can boost successful surface cleaning to more than 80%.

"We are not doing a great job of environmental cleaning," Dr. Qutaishat said. "We can improve environmental cleaning using a pragmatic, quantitative approach that is highly cost-effective."

Standard cleaning processes are based on subjective visual assessment of surfaces. A more effective process focuses on regular cleaning of known high-touch surfaces that are most likely to harbor pathogens as well as terminal cleaning after each patient vacates the room.

Studies have identified 18 high-touch surfaces in patient rooms most likely to harbor pathogens. The highest pathogen load is typically found on remote controls, bed control panels, patient pull cord, toilet and nearby wall areas, faucet handles, and light switches.

Surface contamination is an enduring issue, Dr. Qutaishat noted. Patients in hospital rooms that previously housed a patient with an infection are at significantly higher risk of infection themselves. Methicillin-resistant Staphylococcus aureus can survive on environmental surfaces up to seven months, he noted, E. coli for 16 months. Norovirus remains viable two to three weeks on environmental surfaces while severe acute respiratory syndrome, HIV, and influenza virus remain viable for about a week.

"The evidence is there that pathogens survive for a significant length of time even with cleaning," he said. "Some of them are highly virulent. Norovirus doesn't require a large number of pathogens for effective transmission even after a couple of weeks on a door handle or some other room surface."

A joint effort

The Centers for Disease Control and Prevention published an environmental cleaning toolkit in 2010 as part of infection prevention efforts, Dr. Qutaishat said. The hospital cleaning program should be a joint effort between infection prevention and environmental services. Each department should have clearly defined responsibilities, with structured staff training and direct measurement of cleaning results.

Swab and culture remains the gold standard to test for surface pathogens, but the method is slow and expensive. Fluorescent markers or ATP testing can identify surfaces inadequately cleaned, but cannot verify the presence of pathogens.

Quaternary ammonium, bleach, and accelerated/activated hydrogen peroxide remain the standard cleaning agents, but it is time to retire reusable cotton wipes. Pathogens can survive on the wipes and be moved around the hospital the next time the cloth is reused. Disposable microfiber wipes are much more effective cleaning tools, Dr. Qutaishat said.