When it comes to cleanliness, Queen Elizabeth I (1558-1603) set us all a good example. She took a bath at least once every three months ‘whether she needeth it or not’. In the same way, it makes sense for cleaning professionals to ensure that hospitals are cleaned regularly, whether they appear to need it or not.
A failure to do so can result in a Pandora’s Box of nasty bugs. But this begs a fundamental question – how best to ensure that this container remains closed? The answer is to thoroughly clean, disinfect and decontaminate every surface frequently.
A host of horrifying statistics point to the pressing need to curb infections in healthcare facilities. It has, for example, been estimated that 300,000 patients develop a healthcare-associated infection in England every year, with 5,000 of those cases proving fatal. And a staggering 3.5 million Europeans contract an infection while in hospital every year, with around 2.5 million (equivalent to the combined population of Birmingham and Wolverhampton) dying or being seriously debilitated annually as a result, according to research from the European Centre for Disease Prevention and Control.
LOOKING TO LIGHT
A recent study by Duke University in the United States found that adding short-wavelength ultraviolet-C light (UVC) to standard room cleaning strategies decreased hospital-wide incidence of two common healthcare-associated infections.
The randomised controlled trial conducted at nine hospitals in the south eastern US found that enhanced terminal room disinfection with UVC in a subset of rooms, previously occupied by patients colonised or infected with multidrug-resistant organisms (MDROs), led to a decrease in hospital-wide incidence of Clostridium difficile and vancomycin-resistant enterococci (VRE).
The study, funded by the Centers for Disease Control and Prevention, adopted four strategies – standard disinfection; standard disinfection and disinfecting UVC; bleach; and bleach and UVC.
The UVC device used in the study was a machine that emits a lethal dose of UV light into an empty hospital room. The light waves kill bacteria by disrupting the molecular bonds that hold their DNA together. Overall, there was no significant difference between the standard cleaning method and the enhanced methods for hospital-wide risk of target organism acquisition of all target organisms.
But of all the enhanced cleaning methods, the decrease in risk was greatest during the UVC study period compared with the reference period. The researchers suggested there were several explanations for how enhanced disinfection of targeted rooms with UV light could lead to a decrease in hospital-wide acquisition of MDROs.
By reducing pathogens in targeted rooms, enhanced disinfection cuts down on the potential for subsequent patients in those rooms, and adjacent rooms, to become infected or colonized. And since patients with one type of MDRO are often colonised with other MDROs, an intervention targeting a specific organism, like C. difficile, could decrease the risk of colonisation or infection with others.
In addition, rooms of infected or colonised patients could serve as epicentres for transmission within a hospital through contamination of shared medical equipment and healthcare workers’ hands and clothes. More effective decontamination of these rooms, therefore, could reduce the risk.
ROLE OF ‘MAINTENANCE CLEANING’
“In busy hospitals and clinics, efficient maintenance cleaning is crucial as there is rarely enough time for time-consuming deep cleaning. More stringent hygiene standards, increasing cost pressures and competition make things more difficult,” says cleaning equipment manufacturer Kärcher. It offers cleaning and disinfecting equipment such as scrubber driers for floors and steam cleaners.
Arguing the benefits of steam is equipment supplier Osprey Deepclean: “Dry steam is proven to be effective against ‘superbugs’, and when used in conjunction with an integral vacuum, dry steam safely and effectively removes them – instead of killing them – leaving little scope for antimicrobial resistance.
“Dry steam reduces the need for chemicals, and leaves surfaces clean, dry and ready for reuse. Dry steam cleaner machines are therefore perfect for hospitals, clinics, nursing homes, vets and other health centres.”
Steam cleaners operate along similar lines to pressure cookers – cold water is poured into a sealed boiler and is then heated until it boils and creates a hot supply of steam. The heat can then be increased further so that the steam then becomes superheated.
This so-called ‘dry’ steam contains little moisture and/or water particles. The standard of dry steam dictates that it must not contain more than 5% moisture. The reason for this is that dry steam cannot possess any impurities, but water can. It can be channeled through different cleaning heads. The higher the temperature, the higher the pressure of the steam emitted.
A less traditional non-contact cleaning measure is the use of ultrasonic nebulising equipment. US-based Altapure, for example, offers a high-level disinfection system claimed to kill C. difficile, MRE, MRSA, and viruses, in a treated space in under 50 minutes.
It says: “Merely zapping bugs with UV light leaves a very dangerous bio-burden behind in treated rooms that can infect other patients and hospital personnel.”
The AP-4 is an ultrasonic product designed to deliver a dense cloud of sub-micron droplets. The aerosol is said to deliver gas-like performance that offers three-dimensional coverage and treatment in large areas, multiple connected spaces, complex geometries, long horizontal and vertical runs, and the various surfaces within these spaces, including any equipment or objects located there. The result is said to be a complete coverage and treatment of all exposed surfaces within the treated space.
NO SUBSTITUTE FOR SCRUBBING?
But not everyone is convinced. Delia Cannings, manager of education and training for the Association of Healthcare Cleaning Professionals (AHCP), argues that there is no substitute for good old-fashioned scrubbing, mopping, washing and wiping before conducting any kind of disinfection in hospitals. She says: “Some people believe that, in the healthcare sector, you can go straight into disinfecting without cleaning. But you must clean first, because you have to remove the soil from the surface in order to get to [the pathogens]… physical agitation is a requirement. How that is done will depend on who you work for, what equipment you’ve got access to, how well trained your staff are.”
So, although physical washing and wiping could be mechanical using machines such as steam cleaners or pressure washers, it seems there’s no substitute for the mop and bucket.
Cannings points out that there are a number of disinfectants, sanitisers and cleaning agents that are used together. In a confirmed case of a specific outbreak, the view is that the area should have a detailed clean (edges, ledges, highs, lows, pulling out, pushing in) followed by decontamination (removing that which is invisible in the main) either using vapour technology (which involves bleach-based disinfectants), ozone generators or robots (small mobile machines that give off a vapour).
But, she warns, however well-prepared you are, the incidence of biofilm – a result of the residues of cleaning agents left behind because they haven’t been measured correctly – is increasing so, in effect, the cleaning needs cleaning.
“If [cleaners] don’t dilute [their disinfectants] correctly, they will leave behind biofilm (essentially a transparent membrane surfaces that collects germs and other contamination from the environment). The link between dilution and infection prevention is unrealised. Get the dilutions right and we reduce infections, in my opinion.”