The concept of hygiene for health is never more relevant or more critical than in the healthcare sector itself. Hospitals are the most demanding of buildings, where the highest of hygiene standards must be consistently maintained. How has this sector progressed in recent years, what lessons have been learned and what are the key challenges to be faced in the future? Late Dr Stephen Dalton, vice president, global marketing for healthcare and infection prevention at Diversey in his last interview.
Why are hygiene and high standards of cleaning being vital in the healthcare sector and what are the consequences of poor hygiene standards?
Our understanding of the role that the hospital environment plays in causing Healthcare-Acquired Infections (HAIs) continues to evolve. Within healthcare locations, HAIs create significant morbidity and mortality.
On any given day, about 80,000 patients have at least one HAI, i.e. one in 18 patients in a European hospital has an HAI while in lower and middle-income countries, the figure can be closer to one in five patients (WHO, 2011). Healthcare without infection is a key to patient’s safety goal in all countries.
We must consider the survival of transmissible pathogens in the healthcare environment. For example, if you take the Klebsiella pathogen, it has been recorded living from two hours to 30 months on a surface. Similarly, Acinetobacter can survive from three days to five months and Staphylococcus Aureus (including MRSA) anything from seven days to seven months.
So, that is why the we believe the environment and surface cleaning is as equally important as hand hygiene protocols in combating HAIs. You should think of the two together – fantastic, if you wash your hands when you are visiting or working in a healthcare location, but if the surfaces are not being decontaminated then every time you touch a surface you are exposed again to those pathogens.
Also remember that previous patient illness can affect the risk for the next patient in the same room or even potentially ward area. Dr Jon Otter, the highly respected UK infection prevention expert found that if the person in the room before you had C.diff, your risk of catching it has doubled – and with MRSA the risk is even higher.
What are the most challenging aspects of cleaning and hygiene in the healthcare sector for the team at grass roots level?
I want to split my answer into two parts. One point is in most hospitals, the cleaning team cleans once a day – but people have an expectation the hospital will always be clean. An American study found that over 80 people come in and out of the room in a typical patient day. And the bed rail is touched 256 times a day!
I am not advocating it is cleaned 256 times a day, that would be overkill, but I do advocate you can’t just clean it once and think that the job completely done.
The other part to my answer is that on a more practical note, the amount of technology and equipment now in a hospital room such as ultrasound equipment, MRI scanners or blood pressure monitoring devices, creates its own challenges.
Have the techniques, working methods, tools and equipment developed in recent years to make high cleaning standards achievable?
I look back nearly 15 years when MRSA was a big issue in the UK and there was huge political pressure for things to be done. Consequently, the UK adopted microfibre cloth cleaning – actually after Scandinavia had already adopted it. It became popular because it resulted in an improved level of surface cleanliness.
I would argue though that the adoption of microfibre has brought its own problems. In an industry with a high turnover of staff, who is responsible for washing the clothes? Do they know how often to wash the cloths and the proper washing protocols? And does the hospital cleaning team have all the microfibre cloths needed and how long do they have to spend checking them at the start of each shift?
So now we are seeing rapid take-up of pre-wetted wipes. Pre-wetted wipes mean that you don’t have to dilute the product, you don’t have to worry how much liquid is on the wipe because it is already done for you. It saves time because you don’t have the setup.
Touchless ultraviolet (UV) disinfection seems to be an increasingly popular technique. What are your thoughts on that?
I see it as a useful and additional adjunct to other hospital cleaning methods. When cleaners are not told that their cleaning performance is going to be measured, the average cleaning performance is 50-60 per cent, meaning that if you put 10 markers in a room six will be removed and four will remain.
Patient as customer
If you have patients who have had C.diff or MRSA, when you’ve done your discharge clean, touchless disinfection techniques are a good additional step to reduce the risk for the next patient.
The other thing about touchless disinfection is that in some countries fogging or misting is an accepted thing to do in operating rooms at the end of each day. But fogging can be corrosive and it has health and safety risks in that you can’t go back in to a room until it has cleared. A system like touchless UV eliminates those risks.
In recent years what are the key lessons that have been learnt by cleaning service providers who are servicing hospitals?
Generally, Europe is moving to a US style set-up where the patient is viewed as a customer. Hospitals are encouraging their cleaners to reach out to their patients to check that they are happy because patient satisfaction scores are clearly key. Now other countries have similar ambitions because happy patients tend to recover better.
I think people are understanding the importance of keeping the environment in a hospital not just looking clean but being hygienically clean to reduce infections. They are therefore putting more focus on training people and making sure those people are motivated to do a good job.
Has part of this increased recognition also led to the increasing adoption of the term environmental services rather than hospital cleaner?
Job title change
I don’t think you’d find anyone calling themselves a housekeeper now. Environmental services is the accepted name. Following the US practice, I see it being adopted in the UK but I also see it, or some equivalent of it, being adopted in other countries as people are moving away from housekeeping – mainly I think to convey that this is a step up in terms of the risk they are managing.
What are the most important challenges facing the healthcare sector and in turn the service providers working within it?
One is hand hygiene because it is the perennial issue. The second now is surface/ environmental hygiene and we’ve discussed why that is important and the third is one is trying to stop the overuse of antibiotics. That’s what keeps infection prevention people up at night because the more you use antibiotics, the more resistance there is – ultimately a doomsday scenario if you will but one that I hasten to add is not just around the corner.
Operationally, the reduction in beds in western Europe is a good thing. If you can get people in and out of hospital quicker, it is better for them because they are back with their families or in their own homes. It reduces risk of infection because they are not around for as long and you don’t have to build such large hospitals – but what it does do is put pressure on the turnaround of the rooms and the cleaning.
Because you have a high occupancy all the time you really have to make sure you can clean those rooms efficiently and effectively and deal with the pressures that people don’t want to be kept waiting when they are being admitted to hospital.
The final challenge is understanding that balance between how quickly you can clean a room and how effectively you can clean it. So the faster your disinfectant works, the better it is. And if you have a fast system of touchless disinfection at the end all the better.
You talked earlier about the more emotional connection of the cleaner and happy patient and outcomes. Yet you also said that human error, forced failings are a big part of the problem. What about cleaning robots then in a hospital environment?
For large areas of floors, using robotic cleaners is a compelling argument. Whenever we sell our Diversey robotic floor care machines into hospitals, the infection prevention teams there are generally comfortable with a concept that says you need some human interaction but less people walking up and down corridors for the sake of it – not that floors aren’t very important things to clean — is better. If you have less traffic, you’ve got less risk. In a couple of cases too where we have sold the robotic floor care machines in children’s wards we have actually put shrink wraps on them so they look like toy trains to humanise them.
Dr Steve Dalton