Healthcare Hygiene magazine October 2019 | Page 22

would be cautious about taking environmental samples
from hospital wards on a routine basis.”
Dancer (2004) had pointed out the business case for
cleaning before the reimbursement landscape began to
change significantly, and was ahead of her time in using
cleaning to leverage it as a risk management strategy: “As
cleaning could be a cost-effective method of controlling
HAI, it should be investigated as a scientific process with
measurable outcome.”
To achieve this, Dancer (2004) said, it would be necessary
to adopt an integrated and risk-based approach that would
encompass preliminary visual assessment, rapid sensitive
tests for organic deposits and specific microbiological inves-
tigations. Such an approach has already been established
by the food industry to manage cleaning practices in a
cost-effective manner…”
Dancer (2004) had proposed possible bacteriological
standards for assessing surface hygiene, based on standards
applied in the food industry but modified to reflect the
Experts continued to disagree about the validity
of current benchmarks for defining “clean”
surfaces and debated their merit of serving as
meaningful surrogate measures for
HAI transmission.
differences between risk management in food preparation
and the risk for acquiring infection in hospital. As we have
seen, two features of the standards were the identification
of an indicator organism of potential high-risk to patients in
any amount, and the quantitative assessment of organisms
found within a specified area, regardless of identity.
Dancer (2004) had suggested that there should be <1
CFU/cm 2 of the indicator organism(s) present in the clinical
environment and noted that the identification of an indi-
cator organism should generate immediate cleaning and
disinfection practices. Repeat sampling would be mandatory,
and risk assessment would determine a hygiene review,
additional cleaning, or even the closure of a clinical area
for deep cleaning if appropriate.
Dancer (2004) had proposed that the internationally
recognized figure of <5 CFU/cm 2 could be used as a starting
point in working toward a standard of clean in the healthcare
environment: “The finding of ≥5 CFU/cm 2 from a hand
contact surface, whatever the identity of the organisms,
indicates that there might be an increased risk of infection
for the patient in that environment. This should generate
an evaluation of the cleaning/disinfection practices and
frequencies for that surface. This is based on three suppo-
sitions: first, an increased microbial burden suggests that
there has been insufficient cleaning. This would increase the
chances of finding a pathogen. Second, a heavy microbial
burden may mask the finding of a pathogen. Third, a heavy
concentration of certain organisms implies an increased
chance of finding an epidemiologically related pathogen.”
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As Dancer (2004) had observed, “We need to be able
to judge cleanliness by the same standards, even if this is
done by empirically grading set situations. There are already
internationally agreed microbiological standards for air, water
and food preparation surfaces, so why not for surfaces in
hospitals? … Widespread adoption of standards would
allow risk assessment and evaluation of infection risks to
patients (and staff) in hospitals. The ability to compare results
between different clinical units and different hospitals would
contribute toward further evaluation. Infection control and
domestic personnel could justify their actions regarding
routine and incident measures. Cleaning efficacy could
be subjected to internal audit, with feedback to managers
and the infection control committee for regular review.
These standards would allow national and local audits on
hygiene to be conducted on a scientific basis, rather than
the ill-defined and almost certainly subjective criteria used
to date. Visual assessment of hygiene has been shown to
be a poor indicator of cleaning efficacy.”
At the time of her seminal study, Dancer had indicated
that much more research was needed around all available
microbiological methods, the role of rapid methods such
as bioluminescence, clinical surface definitions, sampling
indications and frequencies, and responsibilities and cost.
She also recommended that researchers “attempt to equate
the environmental findings with the probability of acquiring
a hospital infection,” which has been the Holy Grail in
all aspects of infection prevention-related interventions
for decades.
For example, in 2004, Dettenkofer, et al. performed a
systematic review of the impact of environmental surface
disinfection interventions on occurrence of HAIs. The authors
concluded that the quality of the studies existing at that
time was poor, and none provided convincing evidence that
disinfection of surfaces reduced infections.
Experts continued to disagree about the validity of current
benchmarks for defining “clean” surfaces and debated
their merit of serving as meaningful surrogate measures
for HAI transmission.
Four years after Dancer’s paper was published, Al-Ha-
mad and Maxwell (2008) asked “how clean is clean?” and
confirmed that, “Although microbiological standards have
been proposed for surface hygiene in hospitals, standard
methods for environmental sampling have not been dis-
cussed.” Their study sought to assess the effectiveness of
cleaning/disinfection in critical care units using the wipe-rinse
method to detect an indicator organism and dip slides to
quantitatively determine the microbial load.
The researchers microbiologically surveyed frequent-
hand-touch surfaces from clinical and non-clinical areas,
targeting methicillin-susceptible (MSSA) and methicillin-resis-
tant Staphylococcus aureus (MRSA). A subset of the surfaces
targeted was sampled quantitatively to determine the total
aerobic count. MRSA was isolated from 9 (6.9 percent)
and MSSA was isolated from 15 (11.5 percent) of the 130
samples collected. Seven of 81 (8.6 percent) samples col-
lected from non-clinical areas grew MRSA, compared with
two (4.1 percent) from 49 samples collected from clinical
areas. Of 116 sites screened for the total aerobic count, 9
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