Healthcare Hygiene magazine January 2020 | Page 14

monitored and measured, and what would be appropriate
benchmarks for cleanliness and reduced risk for pathogen
transmission? How should interventions be implemented,
including in-depth study of facilitators and barriers to
real-world implementation?”
“In addition to expanding the use of comparative
effectiveness research and placing greater emphasis
on patient-centered outcomes, future research should
investigate the effectiveness of a number of promising new
technologies and approaches,” said Han. “These include
self-disinfecting coatings and increasingly used surface
markers for monitoring the presence of pathogens. Other
challenges include identifying high-touch surfaces that confer
the greatest risk of pathogen transmission and developing
standard thresholds for defining cleanliness.”
As Han, et al. (2015) note: “We found considerable di-
versity regarding both study design and cleaning/disinfecting
and monitoring methods examined across studies, as well as
many limitations in the evidence base. There was a lack of
direct, rigorous comparative studies of various methods, with
only five studies designed as randomized, controlled trials.
Our review of the literature also highlighted a limited focus
on patient-centered outcomes, such as patient colonization
or infection. Instead, surface contamination was the most
commonly reported outcome.”
The results of these studies suggest that evaluating the
clinical effectiveness of cleaning and disinfecting methods is
challenging. As the researchers explain, “A major limitation
is the gap between optimized use of surface cleaning or
disinfecting agents in studies and practical implementation in
real-world settings (such as appropriate dwell time and type of
surface targeted). Manufacturers provide recommendations
for proper use of their products, but most studies do not
report thoroughness of cleaning or adherence to disinfectant
dwell time; this information also remains largely unknown in
daily practice. An important related concern is uncertainty
by end users about the applicability of some manufacturer
recommendations. Guidance that accompanies products
may be based on laboratory testing under ideal conditions
rather than clinical settings. Recommendations may also be
developed based on certain types of pathogens, but users may
choose to implement a product or technology for broader
effects. Few studies directly compared the effectiveness of
different methods; instead, many used before-and-after study
designs to assess the effect of a single disinfecting method.”
Another challenge to interpreting the results of the current
evidence base, according to Han, et al. (2015) is determining
the specific effect of environmental cleaning and disinfecting
interventions in the context of multicomponent infection
prevention strategies: “Infection prevention comprises many
critical components in addition to hard surface cleaning,
including sterilization of instruments, implementation of
appropriate isolation precautions, and proper hand hygiene.
These and other elements may sometimes be included as
interventions within a larger infection prevention strategy,
limiting the ability to discern the specific effect of any single
approach. These factors also have the potential to modify
the effectiveness of environmental cleaning interventions.
Considerable uncertainty also remains about which surfaces,
including high-touch objects, should be targeted for cleaning
and disinfecting.”
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Four years after Han, et al. (2015)’s summation of the
paltry evidence, Mitchell, et al. (2019) published their
multicenter, randomized trial, known as the REACH study,
evaluating the effectiveness of an environmental cleaning
bundle to reduce HAIs in hospitals.
The Researching Effective Approaches to Cleaning in
Hospitals (REACH) study was a pragmatic trial conducted
in 11 acute-care hospitals in Australia having more than
200 inpatient beds and a HAI surveillance program. The
stepped-wedge design meant intervention periods varied
from 20 weeks to 50 weeks. The researchers introduced
the REACH cleaning bundle — a multimodal intervention,
focusing on optimizing product use, technique, staff
training, auditing with feedback, and communication — for
routine cleaning. The primary outcomes were incidences of
health-care-associated Staphylococcus aureus bacteremia,
Clostridium difficile infection, and vancomycin-resistant
enterococci infection. The secondary outcome was the
thoroughness of cleaning of frequent touch points, assessed
by a fluorescent marking gel.
In the pre-intervention phase, the authors reported 230
cases of VRE infection, 362 of S. aureus bacteremia, and
968 C. difficile infections, for 3,534,439 occupied-bed
days. During the intervention, there were 50 cases of VRE
infection, 109 of S. aureus bacteremia, and 278 C. difficile
infections, for 1,267,134 occupied-bed days. After the
intervention, VRE infections reduced from 0.35 to 0.22 per
10,000 occupied-bed days, while the incidences of S. aureus
bacteremia (0.97 to 0.80 per 10,000 occupied-bed-days) and
C. difficile infections (2.34 to 2.52 per 10,000 occupied-bed
days) did not change significantly. The intervention increased
the percentage of frequent touch points cleaned in bathrooms
from 55 percent to 76 percent and patient rooms from 64
percent to 86 percent.
As Mitchell, et al. (2019) emphasize, “The intervention
does not require new technology, but prioritizes evidence
from previous studies based on feasibility and cost of
implementation, using an implementation science framework
to guide application. This bundle has the potential to be
implemented into various hospital settings. The findings from
our real-world study suggest that improving hospital cleaning
requires a multi-modal, tailored approach that considers the
local setting. By using a bundle approach to improve routine
and discharge cleaning, improved cleaning performance
and a reduction in the number of VRE infections is possible.
Since VRE is a useful surrogate for other bacteria, there are
potential benefits of a tailored cleaning bundle for other
pathogens that survive in the environment. However, we
found no effect of the cleaning bundle on Staphylococcus
aureus bacteremia and Clostridium difficile.”
The REACH bundle— created via a review of peer-re-
viewed publications and guidelines, prioritization of evidence
by an expert panel (with a focus on interventions that were
easy to implement and low cost) —makes recommendations
on optimal types of cleaning agents, frequency of cleaning,
cleaning techniques, auditing strategies, environmental
cleaning staff training, and creating a hospital-wide
commitment to improved cleaning.
Brett Mitchell, PhD, FACN, FACIPC, CIPC-E, a professor
in the School of Nursing and Midwifery, at the University of
Newcastle in Australia, lead author of the study, explains that,
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