Healthcare Hygiene magazine January 2020 | Page 15

To improve

thoroughness of

cleaning, you need
tailored education and feedback of
cleaning outcomes to cleaning staff,
as well as appropriate products
and communication.”
“The bundle is about
a range of important
initiatives needed
to improve hospital
cleaning. They can
be applied in any
scenario regarding
of the pathogen of
concern.” Mitchell
adds, “Cleaning is a
complex activity and
— Brett Mitchell, PhD, FACN,
our study showed
FACIPC, CIPC-E
that range of things
need to be applied to improve cleanliness and reduce
infection rates. Education and training alone, for example,
has been shown in some studies to have benefit, but it is
not necessarily sustained.”
Education of healthcare workers was an essential
component of the bundle. As the researchers emphasized,
“Core training content included cleaning roles and respon-
sibilities, components of the cleaning bundle, and effect of
environmental cleaning on healthcare-associated infections.
The cleaning technique included a de fined and consistent
cleaning sequence, daily cleaning of the high-risk frequent
touch points, use of sufficient pressure and movement, and
adherence to manufacturers’ instructions for product use
(dilutions and contact time). Tailored training activities and
content reflected the context of the respective hospitals,
including existing cleaning products and schedules. Com-
munication was a key strategy to sustaining a hospital-wide
commitment to improved cleaning and bundle components.
Hospital-wide promotional activities were used to raise the
profile and importance of cleaning in reducing infections
and to support a culture shift in environmental services staff.
Daily contact between cleaning staff and ward leaders or
managers was encouraged, with cleaning staff representation
on relevant clinical governance committees.”
The researchers used several strategies to monitor cleaning
bundle implementation, infection prevention, and control
program changes and outbreaks or other issues at each
hospital during the trial period. A key strategy was regular
email and telephone contact, at least monthly, between the
study and site team. The study team also requested that a
monitoring document be completed by the site team every
two months to systematically capture changes in any aspect
of the infection prevention program, including screening
and staffing changes, outbreaks, and the fidelity of the
bundle implementation.
The primary outcomes were incidence rates of HAIs:
Staphylococcus aureus bacteremia, Clostridium difficile
infection, and vancomycin-resistant enterococci infections
(sterile sites only), at each hospital, per 10,000 occupied-bed
days, and the cost-effectiveness of a decision to adopt the
environmental cleaning bundle. The cost-effectiveness
outcome will be reported separately. For the calculation
of healthcare-associated infections, preintervention data
refers to combined data from the historical, establishment,
and control phases and first four weeks of implementation.
Post-intervention data were collected from four weeks after
the start of intervention to allow for a delay in the intervention
effect. Standardized infection definitions were applied.
www.healthcarehygienemagazine.com • january 2020
The secondary outcome was thoroughness of hospital
cleaning, measured by the DAZO Fluorescent Marking Gel
and Ultraviolet Light System. Data collection of cleaning
audits occurred during the control and intervention
period. The outcome was the probability that a dot was
completely removed.
During the study, 25,443 individual frequent touch points
(5,134 control, 20,309 intervention) were audited; 690 of
available beds were audited every quarter. The proportion of
frequent touch points cleaned increased in both the bathroom
and patient room. The percentages of frequent touch points
cleaned before and after the intervention increased from
55 percent to 76 percent for the patient room, and from
64 percent to 86 percent for the bathroom. No changes in
hand hygiene compliance or antimicrobial use were seen over
the course of the trial; however, there was large variation in
antimicrobial use between difference classes.
The researchers report that implementation of the REACH
cleaning bundle resulted in improved thoroughness of cleaning
that continued to improve over the intervention period. The
thoroughness of cleaning at baseline (control) was low. As
the researchers note, “We would expect variation in cleaning
practices to also be present in hospitals excluded from our
study. Our results are similar to previous findings demonstrating
the benefit of using a fluorescent gel to assess cleaning with
provision of feedback to staff; however, our intervention
included other elements, such as a focus on cleaning technique,
training, communication, and correct product use. Using this
bundled intervention, we previously reported changes in
knowledge, practice, and attitudes in environmental services
staff, improvement in the thoroughness of cleaning, and an
overall reduction in healthcare-associated infections.”
Mitchell emphasizes that, “There is no one element of
the bundle that is more important. To improve thoroughness
of cleaning, you need tailored education and feedback of
cleaning outcomes to cleaning staff, as well as appropriate
products and communication.”
Mitchell says it is hoped that use of this bundle correlates
to decreased infection rates. “Of course, cleaning is just one
very important component of an infection control program or
strategy to reduce the risk of infections,” he says. “Improving
cleaning alone will aid a reduction in infection rates, but
other measures such as improving hand hygiene and correct
insertion and maintenance of medical devices are some other
very important measures. What we have shown, using the
highest quality research to date, it that it is possible to improve
cleaning and when you do, it can assist in reducing infection
rates. Our study is a reminder that investment in cleaning and
cleaning staff is a critical element of patient safety in hospitals
and that investment in cleaning (the bundle we tested) is
cost-effective.
References:
Han JH, et al. Cleaning Hospital Room Surfaces to Prevent HAIs.
Ann Intern Med. 2015 Oct 20; 163(8): 598–607. https://annals.org/aim/
fullarticle/2424875/cleaning-hospital-room-surfaces-prevent-health-care-as-
sociated-infections-technical
Mitchell BG, et al. An environmental cleaning bundle and healthcare-as-
sociated infections in hospitals (REACH): a multi-center, randomized trial.
Lancet Infect Dis. 19: 410-18. 2019.
Palmore TN and Henderson DK. Intensifying the Focus on the Contribution
of the Inanimate Environment to HAIs. Ann Intern Med. Oct. 20, 2015.
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