Healthcare Hygiene magazine November 2019 | Page 31

That the protocol has only four steps is
by design, to help overcome challenges
relating to the overall complexity of
cleaning disinfection tasks, the skill and
comprehension levels of environmental
services professionals, and the immense
pressure of room-turnover times.
Variability in cleaning practices is problematic, Dancer
says, because “Different methods, types, application and
frequencies of cleaning destroy any chance of collating
scientific evidence. In addition, cleaners are people who
will clean differently every shift depending on how they
feel. Cleaners cannot be standardized. Nor should they be.”
One might think that basic guidance for environmental
cleaning and disinfection could be construed as naïve
in this age of sophisticated interventions, but as Dancer
and Kramer (2018) emphasize, “Repeated application of
a sequential cleaning system would offer a time-efficient
and effective method for decontaminating a bed space in
the healthcare environment.”
They add further, “It is already known that surfaces are
regularly missed during cleaning, and that time spent cleaning
does not correlate with thoroughness of cleaning. Cleaning
an area in a methodical pattern establishes a routine so that
items or areas are not missed during the cleaning process.
A practical guideline would improve cleaning of high-risk
near-patient sites and could impact HAI risk. Secondly, an
explanatory guide would help cleaning staff to understand
what they should do, when they should do it, and why they
should do it. The principles focus on the occupied bed space
because a vacant bed space receives so-called ‘terminal’ or
‘discharge’ cleaning, for which there is already comprehensive
guidance. An unoccupied bed space is easier to clean as
it lacks patient, visitors, clinical equipment and personal
belongings. However, while there remains a small HAI risk
for cleaning staff from the terminally cleaned bed space,
the risk is arguably greater with a patient in situ. Patients
themselves continually touch high-risk sites, without hand
hygiene reminders or opportunities.”
Lack of compliance with infection prevention practices
in hospitals is well documented in the literature and can be
explained away by everything from deficits in resources, to
time pressure and gaps in healthcare personnel knowledge
about the imperatives of environmental hygiene. Barriers
to optimal practice must be overcome, Dancer says, but
consensus is lacking as to how precisely that can be achieved.
“The most intractable barrier to implementing a stan-
dardized protocol (other than lack of evidence) is usually
due to lack of managerial commitment and support,” she
says. “In addition, cleaning staff require a salary, and more
resources might be needed for a new cleaning process. Plus,
no agreement on methods means that consumable costs
could terminate any willingness to restructure the cleaning
service. How do hospitals in low-income countries afford
expensive disinfectants or automated devices?”
www.healthcarehygienemagazine.com • november 2019
Dancer continues, “Another barrier is the fact that it is
difficult to measure both the cleaning process and surface
cleanliness. Even monitoring the impact of a cleaning
intervention by using patient parameters such as HAIs is
challenging. This is because there are multi-factorial reasons
for HAI occurrence outside the outbreak situation. So,
hospital authorities cannot easily audit the benefits from
their newly implemented universal cleaning protocol.”
To help address the lack of standardization, Dancer and
Kramer (2018) outlined a systematic process by which each
component of environmental hygiene is placed within an
evidence-based and ordered protocol. But when conducting
their literature search, the authors hit a barrier of their
own – they could not identify any papers providing an
evidence-based practical approach to systematic cleaning in
hospitals, and therefore proposed their own, simple four-
step guide for daily cleaning of the occupied bed space.
Their schematic is as follows: Step 1 (LOOK) describes
a visual assessment of the area to be cleaned; Step 2
(PLAN) argues why the bed space needs preparation before
cleaning; Step 3 (CLEAN) covers surface cleaning/decon-
tamination; and Step 4 (DRY) is the final stage whereby
surfaces are allowed to dry.
That the protocol has only four steps is by design, Dancer
says, to help overcome challenges relating to the overall
complexity of cleaning and disinfection tasks, the skill and
comprehension levels of environmental services professionals,
and the immense pressure of room-turnover times.
“Why not keep it simple,” Dancer emphasizes. “So, a
four-step protocol is more easily assailable; easier to teach;
easier to monitor; easier to understand.“
She continues, “People need to know exactly what
they have to do; how they should do it; where and when
they should do it; how often they should do it; and what
the risks are, for themselves as well as patients. They also
need to know the value of what they do, even if this does
not translate into a generous pay packet. In addition,
standardization of the process lends itself to monitoring
and feedback, both of which guarantee a better outcome.”
As Dancer and Kramer (2018) observe, “Cleaners
themselves receive little or no training for what they do,
and any teaching initiatives may be compounded by time,
language and literacy problems. Universally poorly paid,
they are expected to perform a physically arduous and
repetitive job with additional personal risks from cleaning
materials as well as exposure to infected patients. Clean-
ing staff would likely welcome a systematic aid to good
practice with in-built risk assessment for themselves, as
well as staff and patients.”
It is important to note that the four-step protocol
proposed by Dancer and Kramer (2018) targets primarily
environmental services personnel rather than nursing staff,
and as such prioritizes bed-space items and furniture and
not clinical equipment. 
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