Arm yourself with cleaning in the battle against infection

The UK medical infrastructure is set for expansion, both as a result of an aging population, but also increased demands for novel treatments. However, this growth may not occur in the classical large scale hospital. The direction of health reforms suggests that more care will be provided in locations such as nursing homes, doctor’s offices, clinics, hospices, and dental practices. All of these are healthcare establishments and all require to be cleaned to the same high standards.
At the same time, the growing trend towards outsourcing cleaning services favoured by the coalition government means that the number of contractor opportunities will expand, even if individual contracts may be cut back as a result of budget pressures.
Together, these factors mean the potential rewards for cleaning contractors who are willing to invest and commit to cleaning medical facilities are great.

But what risks should concern contractors when entering the healthcare marketplace?
As in all workplaces, a healthy, safe, and aesthetically pleasing environment is reassuring to patients and their families by giving an impression of good quality care while enhancing the reputation of the establishment. Although this is important in all economic sectors, it also serves the healthcare industry in the vital task of the prevention and control of Healthcare Associated Infections (HAI).  
HAIs are all infections that do not originate from the patient’s original condition that caused them to be admitted to the healthcare establishment. In 2009 in the UK approximately 4,800 people per year died of MRSA or C. Diff1, and the overall cost of HAIs to the NHS is estimated to be around £1 billion per year – an expense which excludes the indirect costs related to psychological suffering of patients and their family members as well as lost work time spent in the hospital. Managing the risk of HAIs is the single most significant challenge facing cleaning contractors who operate within the healthcare sector.
Most infections that become evident after 48 hours of hospitalisation are considered to be healthcare acquired. Infections that occur after the patient’s discharge from hospital could be considered to have originated at the hospital if the organisms were acquired during the hospital stay. Currently (December 2010), infection levels in the UK for MRSA and C. Diff are at just over 5,300 people per quarter2. However this data does not include other infections, such as e. coli or norovirus.

HAIs are caused by viral, bacterial and fungal disease causing organisms (pathogens) and it is important to note that not all HAIs are a result of contact with infected surfaces. HAIs of the urinary and respiratory tracts shows that many of these originate within the body, and that only a part of the total will have arisen because infection control practices were inadequate3. Respiratory infections associated with both surgery and intubations are largely caused by the patient’s own organisms, rather than organisms carried through the air or liquids they have ingested.
There is always an element of risk of acquiring HAIs and given colonisation rates in the general population, it is impossible to eradicate all traces of them, so it is the responsibility of those responsible for all aspects of care, from hand hygiene, surgical hygiene, prescribing practice and cleaning to minimise the risk as much as possible.

What types of HAI are there?
There are a number of different types of infection that can occur in many places in the body, the most common of which occur in hospitals are urinary (23 per cent), lung (22 per cent), wound (nine per cent) and blood (six per cent)4.
The most high-profile type of HAI is Methicillin-Resistant Staphylococcus Aureus, popularly known as the MRSA superbug. MRSA includes several strains or types of staphylococcus aureus that is not killed by
B-lactam antibiotics. Around 30 per cent of the UK population carry the SA germ in their nose or on their skin. In healthy people, this does not pose a risk, nor do any adverse symptoms occur.
Another prominent HAI is clostridium difficile (C. diff). Although this is bacteria that is present naturally in the gut of around two-thirds of children and three per cent of the adult population, in some cases it can prove fatal. Older people are most at risk from infection, and most cases occur in people aged over 65.

How has the UK government supported contractors in the fight against HAIs?
Control of HAIs has been a priority for governments of all political persuasions. With the launch of the NHS Plan in July 2000 came the development of detailed action plans to improve the cleanliness of hospitals. Every NHS trust prepared their own action plan, which focused on the elements that comprise the specific patient environment, including entrances and reception areas, visitor and ward toilets, cleanliness, decoration and quality of hospital food.
Then, in a further attempt to tackle the problem, the Patient Environment Action Team (PEAT) was established in 2000 to look at a wide range of cleanliness issues relating to wards, reception and waiting areas. Based on PEAT reports, hospitals are awarded a traffic light colour to denote a good (green), acceptable (amber) or poor (red) performance.
Another innovation of the UK government’s health strategy is the establishment of Patient Choice. In December 2005, patients needing elective treatment will be offered a choice of four or five hospitals. These could be NHS trusts, foundation trusts, treatment centres, private hospitals or practitioners with a special interest in operating within primary care. This is called ‘choose and book’. In the meantime, all patients waiting longer than six months for an operation should be offered a choice of an alternative place of treatment. This was called ‘choice at six months’.
The most recent high-profile development was in 2008, when the government ordered a £57m deep clean, where hospital walls, ceilings, fittings and ventilation shafts as well as floors and equipment were subject to a thorough clean.
The current picture with regard to both MRSA and C. Diff in the UK is positive. While the current rate of infection is still too high, it has declined markedly from the peaks of 2007 and 2008. Latest data from the Health Protection Agency5 suggests a 51 per cent decline in MRSA infections from October – December 2008 to October December 2010 and a 64 per cent decline in C Diff infections over the same time frame. These are good results, but more remains to be done, and the current uncertainty around the NHS risks undoing the good work of the past couple of years.

UK performance
How does the UK compare internationally in rates of HAIs, and how could it improve?
Although Britain has a similar rate of healthcare associated infections as its European neighbours, it has one of the highest MRSA infection rates in northern Europe. In the UK, MRSA makes up 44 per cent of all HAIs, compared to just one per cent in some EU countries.
The reasons for this are much debated, but it is not down to a lack of investment; the UK spends approximately the same amount of money on healthcare as other developed nations6. Some of the more credible explanations show that it appears that strains of HAI which are more prevalent in the UK spread more easily than the strains in other European countries. Furthermore, so many people in the UK are already carriers of the MRSA infection that on a daily basis many are arriving at hospital. To give another example, in recent months, the appearance in the UK of E. coli bacteria carrying the NDM-1 gene7 has been associated with travel to India and Pakistan for medical treatment. A further difference between the UK and the rest of Europe is that the UK has comparatively higher bed occupancies8, which leads to greater opportunities for patient to patient disease transmission.
Other possible explanations include rapid turnover of patients and hospitals operate under considerable financial pressure. These factors, in addition to increasingly short inpatient stays, complicate investigations and effective control measures9.
One of the ways EU countries have addressed the management of MRSA has been to quarantine both areas and workers which are known to carry the superbug. Staff who test positive for the infection are sent home for up to four months and treated with antibiotics. If MRSA is passed on to a hospital ward, the ward is closed, and the whole area is cleaned and disinfected. New disinfection technologies such as peroxide fogging seem to bring benefits, but they require long term logistical planning so that wards can be emptied. The current pressures on the NHS in the UK make it less rather than more likely that this will be achievable in 2011.  

So what is to be done? In the first instance, hand washing is a significant action against the transmission of bacteria. Hand washing rates amongst medical professionals are poor. 2008 Research published in the Nursing Times10 suggests that between 59 per cent and 79 per cent compliance with hand washing guidelines was achieved in one hospital in Ireland. If compliance rates can be moved closer to the 100 per cent, then this will have a significant impact on the transmission rates of all infections around medical establishments.
The second issue concerns cleaning. In early 2011, a number of NHS Trusts are already cutting small amounts of money from their cleaning budgets – under the cost pressures imposed by the Coalition. This is foolhardy and short sighted. Each HAI costs the NHS upwards of £10,000 in lengthier hospital stays and treatment time (without mentioning the personal costs to the infected individuals and their families). The current costs from MRSA and C. Diff are in excess of £20 million per year and this will only increase if cleaning is reduced. It is much better to increase cleaning investment, especially in very frequent cleaning of patient touch points11 and cut infections as a result.
One final thought on the direction of travel for cleaning in the NHS; the localism agenda for the NHS must not be used by either the NHS centrally or the Department of Health as an excuse to walk away from the policy issue of HAIs. The fight against HAIs will continue to require central government intervention and Ministers should take the role of setting national baseline standards and ensuring compliance. Otherwise, chaos will reign and patients will be placed in the impossible position of having to interrogate each individual hospital about its cleaning practices rather than being able to rely on a national Health Service having national cleanliness standards.

3. Sanderson, 1995
4. Emmerson et al, 1995
8. Sanderson, 1995
9. Barker, 1997

For more information
The CSSA is the UK trade association for the contract cleaning sector.
Tel: 0207 920 9632