The five strategies were primarily based on experience from the REACH trial , but we underpinned these by a risk assessment . The risk assessment is critical and should prompt you to think about local context in planning your cleaning bundle . The risk assessment should include questions to consider such as : What are you doing now and what do you need to do better ? Who are you trying to protect ? What kind of harm are you dealing with ? What is the likelihood of that harm coming to fruition and what are the consequences of that harm ?” incidence , you need to have many patients in your trial , or numerous sites in your studies to be able to really show true differences where they exist , therefore I think bundles are used to get the biggest impact on infection reduction , which helps reduce the required sample size . Second , infection prevention and control is multi-faceted , and interventions such as environmental cleaning are linked in many aspects , so trying to pick just one of those to find the relative impact of it , is always going to be difficult . When it comes to cleaning in the healthcare environment , there are numerous factors that will impact the efficacy and the efficiency and the outcomes . For example , it ’ s not just about the products but how they will be applied or used -- and many more . So , teaching about myriad individual factors can be more difficult than explaining how the multiple interventions fit together in a bundle to make the greatest impact on HAIs .”
There are several important inter-related environmental cleaning strategies that are used to reduce the risk of HAIs , including product and approach used for cleaning , technique , education and training , audit and feedback , and communication . These are based on the bundled approach of the Researching Effective Approaches to Cleaning ( REACH ) trial , spearheaded by Mitchell and his colleagues and tasked with evaluating the effectiveness of an environmental cleaning bundle to reduce HAIs in hospitals .
“ The five strategies were primarily based on experience from the REACH trial , but we underpinned these by a risk assessment . The risk assessment is critical and should prompt you to think about local context in planning your cleaning bundle . The risk assessment should include questions to consider such as : What are you doing now and what do you need to do better ? Who are you trying to protect ? What kind of harm are you dealing with ? What is the likelihood of that harm coming to fruition and what are the consequences of that harm ? This risk-based approach to cleaning and disinfection helps hospitals implement the five strategies when addressing their HAI-reduction objectives .”
Mitchell continues , “ When thinking about a risk assessment , you can consider the surface risk profile , the patient risk profile , and the pathogen risk . The surface risk profile includes considering what you are trying to clean , and how you are going to do that within the context of that actual surface . The patient risk profile refers to the people you are trying to protect and in what setting . The third component of that riskbased assessment is to examine the pathogens from which you are trying to protect patients . The setting is important . Protecting patients from pathogens in an aged-care facility , for example , might be very different from protecting patients in a hospital ward or in the intensive care unit . So , these three components – the surface risk profile , the patient risk profile , and the pathogen risk profile are important parts of that overall risk assessment that should be conducted before selecting a cleaning and disinfection approach that implements the interventions in the bundle .”
When it comes to who in the hospital should conduct the risk assessment , Mitchell advocates for a team approach .
“ I believe this would start and be led by the infection prevention and control team , because the members of this group are going to understand the local epidemiology , particularly around the pathogen risk profile and the patient risk profile . There are many other considerations , of course , so involving appropriate stakeholders is important . The team should be multi-faceted and include the hospital cleaners , environmental services managers , and clinical and patient safety staff . When you get to the detail of the bundle itself , specifically the product and approach component of that , there are many things to consider , including health and safety considerations . Therefore , engaging stakeholders in those discussions is important .”
The REACH Trial
The REACH trial from 2019 was a pragmatic trial conducted in 11 acute-care hospitals in Australia having more than 200 inpatient beds and a HAI surveillance program . The researchers introduced the REACH cleaning bundle — a multi-modal intervention , focusing on optimizing product use , technique , staff training , auditing with feedback , and communication — for routine cleaning . The primary outcomes were incidences of healthcare-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 of that trial , the authors reported 230 cases of VRE infection , 362 of S . aureus bacteremia , and 968 C . difficile infections . 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
12 october 2023 • www . healthcarehygienemagazine . com