Microbiologists play dual roles, examining germs under a microscope as well as looking for them flourishing elsewhere in their hospitals. Dr Dhruv Mamtora, HOD Laboratory and Infection Control, Wadia Hospitals (Mumbai); Dr Anusha Rohit, Head of Microbiology and Chair of Infection Control, Madras Medical Mission (Chennai); Dr Manisa Sahu, Chairperson, Hospital Infection Control Committee, Balco Medical Centre (Raipur) and Dr Rahul S Kamble, Consultant Clinical Microbiologist, Lilavati Hospital (Mumbai) discussed how hospital housekeeping directly impacts infection control, lacunae in the execution, new solutions and more.
Gaps in hospital housekeeping
Some issues are common to the period before the pandemic, and the present. “Cleaning is not just about the cleaning agent; physical scrubbing is needed to remove biofilm from various surfaces,” said Dr Rohit. At her facility, she has led a shift towards disinfectants that do not produce volatile organic compounds that may be harmful to healthcare workers. Aldehyde-based chemicals have been phased out.
“Processes should be as simple as possible. We cannot have ten different products to be used on different surfaces in the same room,” she continued. Why? Because every process and product should be easy to execute or use by the janitorial staff.
Some years ago, Dr Sahu noticed that her hospital’s stock of disinfectant was being consumed at a suspiciously slow pace. “On rounds, when I asked the staff to show me how they were preparing the cleaning solution, I saw that they were using the incorrect dilution, which would not have been effective in disinfection.”
Everyone agreed on the importance of checklists: different ones for different rooms, and different colours for high-touch points. Despite the inherent risk of manipulation of physical checklists, digital checklists have not yet made inroads.
Air quality in healthcare facilities
“We now know that aerosol-generating procedures can transmit coronavirus. We need to have distinct, different, well-defined air handling systems for areas with Covid-positive patients, Covid-negative patients and the triage area,” said Dr Mamtora. “These cannot share air.”
Terminal filters, inline filters and removable filters of the HVAC system all need to be regularly cleaned, and replaced if not working. Some of these are not easily accessible. During the height of the pandemic, the immense load of patients made it very difficult to clean the ventilation system.
Dr Kamble said: “During this time, AHU duct cleaning was skipped, especially in areas like OTs and cath labs. This led to the growth of fungal organisms on filters, like A.niger and A.flavus. We have seen many secondary infections by organisms that rarely caused infections earlier. These organisms are all environmental pathogens, hence, cleaning becomes important.”
UV or not to UV
Previously, UV used to be used in isolation rooms for TB patients. This is now making a comeback in the times of Covid (along with negative air pressure in patient rooms). Not everyone is convinced.
Said Dr Rohit: “UV works only when it falls directly on the microorganism to be killed, but present solutions tend to have shadow areas. It may not be useful for every area, but may be useful for disinfecting filters and AHUs. There is no one-size-fits-all solution. I would like a solution to be validated before implementing it.”
She advocates a return to the basics. For example, very often, the AHU system itself may not be air-tight, leading to air leaks. These elementary problems need to be taken care of first.
At Dr Kamble’s hospital, germicidal UV lights have been fitted in the HVAC ducts. He said, “We are planning to get portable UV lights which will supplement manual disinfection of terminals, after transfer or discharge of a patient. If installed properly and used as instructed, UV has no harmful effects on human beings.”
All housekeeping requires monitoring
“The pandemic has reminded us of the need for surveillance to ensure continued compliance. Whether done by in-house or outsourced staff, there is always a chance of error. To improve results, we need to help the staff understand how their work directly impacts patients’ lives,” said Dr Rohit. At Dr Sahu’s hospital, the infection control officer interacts with the housekeeping staff at least twice a week.
Hospital infrastructure may differ (a heritage structure vs a new skyscraper), as may cleaning needs in different areas of a hospital (ICUs vs billing desks). All need monitoring.
Once, Dr Rohit decided to check if healthcare workers were sanitising their hands in ICUs, by weighing bedside hand sanitiser bottles over consecutive days to determine consumption. On the third day, the ICU nurse asked her when she would be coming the next day, so she could empty out a little sanitiser from the bottles and be ready for the inspection!
What has changed?
“The principles of cleaning and products have not changed much over the years. The common sense approach is still most effective. Hospital management may compile the most expert of cleaning SOPs, but if the janitorial staff doesn’t know how to clean, it is of no use,” warned Dr Mamtora.
The choice of chemicals may or may not have changed. Dr Sahu said: “Earlier, we used hydrogen peroxide. When Covid guidelines came, we switched to hypochlorite but didn’t find a major difference in the results, and switched back to peroxide. However, the frequency of cleaning high-risk areas has definitely changed.”
At Madras Medical Mission, hypochlorite is used for critical areas, and soap and water for others.
There was consensus that housekeeping expenses have definitely increased. The renewed focus on hand hygiene, and the need for more disinfectant have driven up costs by 15-40%.
There is a corresponding willingness to spend more as well.
Speaking about the attitude of even healthcare workers towards infection control officers, Dr Rohit said: “Earlier, people thought we were just walking around with books, collecting and collecting data. The biggest benefit of the pandemic is that people are more conscious about infection prevention.”