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Table 4: Questions from the Healthcare Cleaning Forum 2018

From: Keeping hospitals clean and safe without breaking the bank; summary of the Healthcare Cleaning Forum 2018

  Questions on the technical process of cleaning:
Q: In the process of wiping a surface clean, how many variables are involved?
A: Please see Table 1 .
Q: Is the use of probiotics allowed in the healthcare sector for cleaning and can this be a solution for difficult to reach surfaces?
A: Emerging evidence suggests that seeding the hospital environment with Bacillus spp. spores may reduce the level of pathogens that are culturable from surfaces. Whilst this could be as a result of competitive ecological exclusion, it could be possible that the Bacillus spores are merely masking the presence of pathogens. Further evaluations of this approach, including clinical outcome studies, are required.
Q: Is a combined disinfection and detergent wipe better?
A: It depends on the application. There are instances where it is better, but other instances where a disinfectant may not be required. Please see Table 2 .
Q: Are bacteriophage-based disinfection technologies (aerosolized for instance) considered as a complementary solution for disinfection?
A: Bacteriophage-based disinfection of the environment, whether applicable to surfaces or air, deserves both a literature search (particularly in Russian) and further in vivo and clinical research.
Q: Is it worth investing in an airborne disinfection solution?
A: There is emerging evidence that contaminated air may be involved in the transmission of pathogens that were traditionally associated with contact transmission, such as C. difficile and Acinetobacter spp. Further research is needed to understand the role of airborne transfer and airborne disinfection in hospital environmental hygiene.
Q: Does the cleaning of equipment wheels in ward areas help in reducing infection?
A: There is no evidence-based research demonstrating that cleaning of equipment wheels in regular ward areas helps to reduce infection; it is usually recommended at entrance of high-risk areas (ie. operative theatre), but further research is needed for definitive guidelines to be recommended.
Q: With no-touch cleaning and disinfecting, how is the soiling contamination removed? If the soil remains behind, is it possible to disinfect?
A: The room or area should be cleaned to remove dirt and organic soiling before an automated room disinfection system is applied. Please see also Table 2 for definitions.
Q: How do you deal with the issue of shadows in UV (ultraviolet light) systems?
A: Whilst the efficacy of UV systems in areas that are out of direct line of site of the UV device receive a lower dose of UV, they do receive a dose of UV due to reflection from other surfaces. The impact of line of sight in UV room disinfection can be mitigated by staging the device in different parts of the room, or using multiple emitters. The only solution is to change the angle of the UV light or to use alternative methods for decontamination.
Q: How important is cleaning of ceilings? How important is selection of building materials so that surfaces are less prone to infection?
A: Cleaning of ceilings is not that important as patients do not come in contact with ceilings. Surfaces must be chosen that are chemically resistant and easy to clean (non-porous). No surface is “resistant to infection”; some surfaces could be less prone to contamination. Please see also Table 2 for definitions.
Q: Have either hydrogen peroxide vapor (HPV) or UV-C devices been proven superior to the other in preventing surgical site infections?
A: To the best of the authors’ knowledge, none of the two methods has been associated with a significant reduction in surgical site infection in a controlled study.
Q: What are your thoughts about preventive (not corrective) disinfection with UV-C in high-risk areas after standard cleaning procedures?
A: Most studies that tested the impact of UV devices in healthcare settings used the devices to treat the rooms of patients known to be infected or colonized with a pathogen. There is a theoretical possibility that using UV more regularly would have an impact, but this requires further evaluation.
Q: What is your opinion on the overuse of chlorine and its health impacts in our hospital cleaning personnel?
A: On the one hand, we need chlorine, as it is one of the few active substances on spores, easily available and cheap. On the other hand, we can reduce the risk of respiratory and muco-cutaneous toxicity by always wearing appropriate protective equipment, using chlorine in the recommended concentration and only in the required situations. Viable alternative sporicidal agents to chlorine (such as peracetic acid and hydrogen peroxide-based chemistries) are now available, and should be considered.
  Strategic Questions for Companies:
Q: For an experienced cleaning vendor wanting to enter into the healthcare cleaning sector, what advice would you give to the company?
A: Get the best training in the field with infection control and hospital cleaning professionals.
Q: Is there a guide for presenting a business case for improving cleaning practices to hospital administrators?
A: There are a number of published papers that provide help and support with business case writing – the authors are happy to provide further information upon request.
Q: Making certified cleaning professionals will cost more money. How to convince finance people from hospital to prioritize quality of cleaning instead of the budget?
A: Professionals’ certification should be part of hiring conditions and over the long-term, not be associated with significant cost increases for the institution. Return on investment would be evident as soon as any adverse event linked to misuse of cleaning methods/techniques related to the absence of adequate training/certification would occur.
Q: Do you think the move towards biosurfactants and microorganisms in cleaning chemicals will affect the industry?
A: Most probably not. The use of products respectful of the environment will, however, gain momentum.
  Strategic Questions for Hospitals/Institutions:
Q: Can (and should) patients be educated so that they can assess the healthcare facility they are staying?
A: Patients’ participation in IPC is advocated and could help institutions to take actions (see paper).
Q: How can cleaning be validated without standard methods to measure cleanliness?
A: There are different methods to assess cleanliness, but no universal standards. Further research is needed to propose and promote universal standards.
Q: What is the best way to measure cleanliness in a hospital room, and is it in real-time?
A: Visual inspection, fluorescent markers, and ATP measurements can be used in real-time; bacterial cultures of an area take more time and use more resources.
Q: How do cleaning and disinfection affect the rates of urinary tract infections?
A: To the best of the authors’ knowledge, there is yet no study that relates a possible relation between surface cleaning and urinary tract infection rates.
Q: Soft surfaces like mattresses and stretchers are commonly damaged in healthcare; how important is surface integrity in infection prevention?
A: It is virtually impossible to clean a damaged surface. Surface integrity must be preserved if a surface is to be cleaned.
Q: What is the recommended practice to suppress Clostridium difficile spores from the hospital environment?
A: Most experts recommend the use of a sporicidal disinfectant such as chlorine, chlorine-containing, or peroxygen-based substances to clean rooms or wards hosting patients colonized or infected with C. difficile and to control C. difficile in hospitals.
Q: Do you have any good success stories or tips to help engage healthcare workers to work closely with cleaning service providers?
A: Yes, there are documented success stories, but there is no universal model yet.
Q: Should IPC teams train hospital cleaning personnel?
A: IPC team members should be involved in hospital cleaning personnel training, together with the key collaborators/head of the hospital environmental cleaning department.
Q: Would a fixed ratio of hospital cleaning personnel per hospital bed be a helpful key performance indicator?
A: Yes it could be a very useful (structure-level) performance indicator; however, one would need further research and optimal adjustment to develop and propose such a model.
Q: How could HPV and UV be implemented within mixed and open wards or in an ICU?
A: Although possible, their application could be quite challenging in conditions with high occupancy bed and rapid turnover rates because areas treated using HPV or UV need to be vacated by patients and staff.
Q: Is average patient length of stay aggregated on the basis of underlying morbidity a better measure of infection cost than solely monetary values?
A: Yes, indeed. Most estimates of the monetary impact of infections are centered on increased lengths of stay. There are however many additional aspects to include in cost-effectiveness analyses.
Q: What is the recommended time for cleaning single patient room, a 4 bed-room and a 6 bed-room?
A: There is no standard time. Models need to be developed and validated.
Q: What is your perspective of HPV and UV disinfection systems in improving bed turnaround time?
A: Both HPV and UV will extend bed turnaround time (HPV more so than UV). But, under defined circumstances, both HPV and UV have been associated with reduced heathcare-associated infections. Therefore, there may be a net improvement in patient throughput. More evidence should however be generated before recommendations could be established at large.
Q: How should the person responsible for the environmental services in a hospital be recognized/ should they earn more for becoming excellent at their job?
A: Training, permanent position, job recognition, certification, and job progress are essential to maintain motivation, as in other professions.
Q: Is there any data on the cost of bed disinfection per bed in any EU member country?
A: The cost of cleaning/disinfection will vary widely based on the methods used and the local approach to delivering cleaning and disinfection.
  Broader Issues:
Q: How do you educate people in the developing world about health care hygiene, where the level of literacy and awareness is so low?
A: The level of literacy is not the most important parameter in maintaining the hospital environment clean; hospitals in low and middle resources countries can be maintained at a very high level. As mentioned above training, a permanent position, job recognition, certification, and job progress are essential to maintain motivation, as in other professions.
Q: What is your key target for the next 12 months with regard to healthcare cleaning?
A: See the proposed research agenda (Table 3 ). Not all points will be addressed over the next 12 months, but this is the direction in which we would like to develop the field.
Q: Would television ads be useful for increasing public awareness?
A: This approach certainly deserves to be tested.
Q: In the private sector, a person who is persistently non-compliant is disciplined. Why can’t this be done in healthcare settings?
A: It has been done, but is certainly rare. Evidence suggests that a “sticks and carrots” approach to improving human behavior works best, with incentivizing the good more effective than penalizing the bad.
Q: What are the top factors that lead to lower healthcare-associated infection rates in hospitals?
A: Successful hand hygiene promotion is the top priority, and has been associated with significant risk reduction. Prevention of device-associated and surgical site infections are certainly key priorities together with appropriate use of antimicrobials. Hospital cleaning is part of key strategies to reduce the bio-burden from the environment associated with the risk of cross-transmission and spread of multi-resistant organisms, linked to almost all infections in healthcare.
Q: Are we ready for new critical outbreaks like Ebola?
A: Pandemic preparedness has improved, informed by outbreaks such as the Ebola outbreak in West Africa, as recently demonstrated in the handling of the recent outbreak in RDC. Handling such risks however merits constant attention and adaptation of both patient care and environmental control protocols.
Q: Without any standardized and validated cleaning methods how can an infectious diseases specialist approve a cleaning contract?
A: There is definitively a need for universal, standardized and validated cleaning protocols, as discussed in the paper.
Q: Using ABHR instead of hand washing was a game changing strategy for hygiene. What is the game changer in surface cleaning in terms of chemical, process, materials, equipment, etc.?
A: Developing a model for the implementation and culture change of environmental cleaning best practices could constitute the solution.
Q: Is there a guide or reference on the scope of the work of healthcare workers and cleaning service providers?
A: To the best of the current authors’ knowledge there is no such universal guide; further development is needed.
Q: Should national healthcare system reimbursement schemes (such as the NHS) reward/promote prevention in hospital cleaning?
A: This tool might be part of a solution; yet one must first develop universal recommendations before one could propose such a tool.
Q: Do you think we can improve the human factor without investing more in training and monitoring hospital cleaning personnel?
A: No, training and monitoring is key to improving behavior.
Q: Can we automate the human factor improvements?
A: Understanding human factors is vital to improving human behavior. Automation can help in some situations; it cannot replace optimal behavior.
Q: What is your opinion on the report of the Dutch Health Council saying that there is a serious risk of bacteria getting resistant against disinfectants?
A: There is no evidence that microbes become resistant to most disinfectants at clinically meaningful levels. However, considering that resistance to antiseptics, as well as to antibiotics, antiviral-, antifunfals, and antiparasitic agents do exist, careful attention should be recommended for specialized research laboratory so that emergence could be traced as soon as possible if it would appear.
Q: When there is outbreak, it is often blamed on cleaning service providers not doing a good job. How can we change the perception of “teamwork” among all stakeholders?
A: Outbreak investigation and control is a challenge. Cross-transmission risk can be controlled most frequently by multimodal, multi-disciplinary interventions involving all health staff at multiple levels. Environmental control is key and most frequently cleaning services providers and/or personnel are accused of not doing an appropriate job. Although it is most frequently not the case, outbreaks associated with the lack of appropriate environmental control have been clearly identified.
Q: When will WHO guidelines be updated to adapt to new technologies?
A: There are currently no WHO guidelines on environmental control including recent and new technologies; the authors have no information regarding the possible update of WHO guidelines.
Q: Is it possible to get the presentations from today’s event?
A: Each of the presentations are available on the website of the Healthcare Cleaning Forum by clicking on the individual speakers [33].
Hand Hygiene References
Hand Hygiene: Numerous questions on hand hygiene came up during the forum. Because this paper is not on hand hygiene in particular, there are a number of references below that contain all of the pertinent information.
[7, 34,35,36,37,38]