rates , among other variables , then the removal of dirt constituted a science in its own right .”
Those early microbiological standards proposed two approaches : The identification of an indicator organism of potential high-risk to patients (< 1 CFU / cm2 ) from hard surfaces , and the quantitative assessment of organisms recovered from a hand-contact site , regardless of identity ( aerobic colony count ( ACC ) < 5 CFU / cm2 ), according to Dancer ( 2023 ). These standards are based on surfaces routinely cleaned with detergents , not disinfectants .
“ After years of work , I still support the magic ‘ 5 ’ courtesy of the food industry ,” Dancer says , in reference to a standard that is applicable to healthcare . “ For hand-touch sites beside the patient on all wards , hard surfaces should be < 5 CFU / cm2 . Critical care , BMT units and cancer wards may require a more stringent standard . These CFU are aerobic microbes , including fungi ; they do not include viruses or parasites , etc .”
As long as there remains any skepticism of pathogen reservoirs in the healthcare environment as causing HAIs , advocacy of environmental hygiene is stalled . An updated microbiological standard of “ clean ” utilizing tangible counts “ would enable researchers to model bioburden against a range of parameters , including cleaning and decontamination methods , in order to find the evidence that was lacking ,” Dancer ( 2023 ) says . “ Finding ≥ 5 CFU / cm2 from a hand contact surface , whatever the identity of isolates , indicates that there might be an increased risk of infection for the patient in that environment . This should generate an evaluation of cleaning / disinfection practices and frequencies based on three suppositions : 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 specific organisms implies an increased chance of finding an epidemiologically related pathogen , such as coagulase-negative staphylococci and S . aureus . Given that it takes as little as 5 CFU of S . aureus to initiate infection , the choice of 1cm as the surface area standard was deliberate . The area of the top of an adult digit is close to 1cm , with that of the thumb even larger . Sampling visually clean hands repeatedly furnish multiple CFU of skin organisms but few pathogens including S . aureus .”
The Need for Better Microbiology Training of EVS Personnel
Stephane Dancer believes that environmental services personnel would benefit from education in microbiology so that they understand the rationale for infection prevention , as well as the cleaning and disinfection practices in which they engage daily .
“ I don ’ t think microbiology education is part of the normal induction for UK cleaners ,” she says . “ But every time I ’ ve given a cleaning lecture to audiences containing cleaning staff , or even audiences comprised entirely of cleaning staff , I have been amazed at the reception . They love to hear about hospital ‘ germs ,’ including what they are , what they look like , what they do to patients . They also are interested in what the role of cleaning staff is to control these germs . And I ’ ve had better and more relevant questions on cleaning from such audiences , than I ’ ve ever had from an audience of medical microbiologists !”
But are hospital cleanliness standards useful ? Dancer says yes , given that a range of microbiological benchmarks have been used to assess disinfectants , cleaning practices , cleaning interventions , automated devices , and antimicrobial surfaces , adding that surface counts can be modeled against hand-touch frequency , HAI rates , air counts , cleaning efficiencies , cleaning frequencies , and additional methods for monitoring surface cleanliness .
But Dancer ( 2023 ) cautions , “ However , the choice of microbiological standards depends on multiple factors , so that every healthcare institution should decide on the standards that works for them . Once implemented , the data can be collected over time and analyzed according to HAI risk . Every hospital is different and only by analyzing long term trends will relevant indicators or triggers for likely infection incidents and even outbreaks become apparent . Universal hard surface standards require robust background data as well as consensus over cleaning practices .”
She adds , “ Establishing some universal standards for surface cleanliness would undoubtedly help focus attention on what cleaning actually is , and what it does . As for SOPs , these should reflect type of hospital , unit , patient vulnerability , and infection risk . Working toward an evidence-based benchmark should encompass routine cleaning practices , cleaning products , sampling methods and laboratory process . It is entirely appropriate for each institution to decide on the level of cleanliness deemed appropriate for its patients therein , with long term monitoring to establish range and trends of bioburden .”
One of the most significant barriers to proper hospital cleaning and disinfection that Dancer alludes to in her paper is the need to elevate the environmental services profession to enhance dignity of personnel and re-emphasize the importance of environmental hygiene in HAI prevention . Although EVS personnel are on the frontline in the battle against pathogens , there persists a knowledge-practice gap that continues to impact compliance with evidence-based practices for cleaning and disinfection .
“ It ’ s taken a long time to get cleaning onto the infection prevention radar ,” Dancer says , “ Practices are still evolving . As soon as outbreaks of pan-resistant pathogens become common place in healthcare ( due to advancing antimicrobial resistance ) you can expect lots more attention on cleaning and decontamination of the environment . Behavioral science ? Look at hand hygiene compliance rates . This has been promoted on a global basis , but healthcare personnel still don ’ t clean their hands when they should . Cleaning quality will be easier to implement ( especially if standards are employed ) because you could design operating procedures that factor out behavioral aspects for the most part . This isn ’ t an advertisement for automated devices , either ; I ’ m thinking about direct observation of cleaning practices ; a checklist ; supervisor sign-off ; cleanliness monitoring ( plus feedback ) built into the framework , etc .”
Regarding the outlook of hospital cleaning , Dancer ( 2023 ) states , “ There remain issues regarding hospital cleaning despite its undoubted importance for both aesthetic appearances and infection control . One of the most pertinent is to establish some form of training and advancement framework for people who clean hospitals , and indeed , other public venues . Removing dirt is not quite as simple as it sounds . There are numerous methods for wiping , mopping , dusting , and decontaminating surfaces to start with , and ever-increasing product choice , including automated devices and novel disinfectants . Indeed , a risk-based approach to cleaning in the healthcare environment is still in its infancy . This is perhaps because a ward , rather than a household or office , is an unnatural and unpredictable environment , so
24 september 2023 • www . healthcarehygienemagazine . com