Healthcare Hygiene magazine January 2020 | Page 13

cover story
Making the Case
for Cleaning
By Kelly M. Pyrek
As
Palmore and Henderson (2015)
acknowledge, “The relative
This is the first
role that the environment plays in the
in a two-
transmission of HAIs has been a topic
part series
of decades-long debate, with persons in
examining the
the healthcare epidemiology community
clinical and
vacillating between skepticism and con-
fiscal aspects
viction. Unlike near-universal acceptance
of making
of the importance of hand hygiene, the
the case for
prevailing view of the contribution of the
environmental
inanimate healthcare environment to the
hygiene.
spread of HAIs has swung back and forth
like a pendulum. Both cultural shifts and
new studies have elicited opposing opinions about the role
of the environment in HAI transmission and the corollary
role of disinfection in reducing these infections. Convincing
healthcare personnel to clean their hands at every opportunity
is challenging but maintaining a hospital environment that
is free from contamination is perhaps even more difficult. A
major challenge in determining the precise contributions of
the environment to HAI transmission, Palmore and Henderson
(2015) add, “is the difficulty of designing studies that are
capable of yielding high-quality data.”
The lack of rigorous evidence supporting the role of
environmental hygiene was addressed several years ago
in a study published in The Annals of Internal Medicine,
when researchers at the University of Pennsylvania School
of Medicine emphasized that more evidence was needed to
identify best methods to clean hospital rooms and thereby
prevent infections. This study acknowledged a lack of
evidence as to which is the most effective at reducing HAIs.
The review, led by Craig A. Umscheid, MD, MSCE, an assistant
professor of medicine and epidemiology at the University of
Pennsylvania, Jennifer Han, MD, MSCE, an assistant professor
of medicine and epidemiology, along with Brian Leas, MS,
MA, and Nancy Sullivan, research analysts in the ECRI-Penn
AHRQ EPC, revealed major gaps in existing evidence for the
Editor’s note
www.healthcarehygienemagazine.com • january 2020
best practices for cleaning hospital room surfaces to prevent
HAIs and revealed major gaps in existing evidence for the
best practices for cleaning hospital room surfaces.
The researchers found that comparative effectiveness
studies were uncommon; such studies would have directly
compared different ways of cleaning, disinfecting, and
monitoring the cleanliness of hard surfaces in order to
determine which were most effective. There were also
relatively few studies that focused on measuring outcomes
of most interest to patients, such as changes in HAI rates
or the presence of pathogens on patients. Only five studies
were randomized controlled trials. Instead, the existing studies
compared the magnitude of surface contamination after
cleaning with an agent to the magnitude of contamination
before cleaning. More than 65 percent of the studies assessed
surface contamination as the primary outcome. Less than
35 percent reported on patient-centered outcomes, such as
HAI rates or acquisition of a specific organism in the body,
known as colonization. The researchers examined three
broad categories of evidence: which agents and methods
were used to clean hard surfaces; what approaches were
available to monitor the effectiveness of cleaning; and what
systems-level factors are needed for cleaning and monitoring
to be successful.
“Our goal was to provide a comprehensive review of
evidence in all three domains,” said Umscheid. “While there
is a clear need for more patient-centered and comparative
effectiveness research, the findings that do exist provide a
good place to start in terms of a hospital or health care entity
seeking information on ways to mitigate healthcare-asso-
ciated infections.”
Among its findings, the researchers identified several
studies showing that rates of C. difficile fell with the use of
bleach-based disinfectants but that a chlorine dioxide-based
product was ineffective in reducing C. diff contamination
and infection rates. In addition, six studies integrating
various wipes moistened with hydrogen peroxide and
other chemicals into preventive strategies reported positive
outcomes, including sustained reductions in HAIs. Seventeen
studies implementing “no-touch” modalities to clean hard
surfaces — such as devices that emit ultraviolet light or
hydrogen peroxide vapor — reported positive findings,
with three specifically demonstrating reductions in infection
rates. Seven of eight studies evaluating enhanced coatings
on hospital room surfaces, such as copper-coated bed
rails, reported positive findings. Surfaces made of solid,
copper-based metals or alloys continuously kill bacteria that
cause infections.
The researchers also highlighted several priority areas for
future research, based on their review of the evidence and
interviews with leading experts. As Han, et al. (2015) note,
“Future research on environmental cleaning and disinfecting
to reduce HAIs should address the following key questions:
What surfaces, including high-touch objects, should be
cleaned and disinfected? How should surfaces be cleaned
and disinfected, and what is the comparative effectiveness of
different methods? How should cleaning and disinfecting be
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