Recognising the crucial element of cleaning

The role of cleaning in fighting infections and bacteria is of growing importance to healthcare providers.

C. difficile, commonly known as C. diff, is a virulent strain of common bacteria carried harmlessly in the gut of many adults, and half of all children aged under two. Unlike MRSA, C. difficile is not resistant to antibiotics, and not officially recognised as a superbug by the Department of Health.

C. diff poses a great danger to patients. After experiencing symptoms such as mild diarrhoea or violent illness, the infection sometimes causes ulceration and colon bleeding. This can lead to perforation of the intestine, causing peritonitis – a serious inflammation of part of the thin membrane in the intestinal tract. Older patients are most at risk, with more than 80 per cent of all C. diff cases reported in people over 65.

The incidence of C. diff can be in part blamed on the use of antibiotics, which kill off other bacteria in the gut that would have ensured C. diff did not become toxic. Another problem is that C. diff is resistant to measures used to combat other hospital-acquired infections.


Methicillin-resistant Staphylococcus aureus (MRSA) is a germ resistant to penicillin and its superior cousin, methicillin. It is estimated that between 20-40 per cent of us carry the MRSA bug, mostly in our noses or on our skin. Like C. diff, MRSA is harmless most of the time, although it can cause boils or other minor infections.

Since MRSA was first observed in the 1960s, it has grown steadily, and while it still may be a relatively benign parasite in the general community, in healthcare environments it can be deadly. Up to 100,000 patients fall victim to some form of infection in hospital every year, while treatment costs are estimated to drain up to £1bn from the NHS every year.

Although it is true that cases of MRSA increased by around 600 per cent between 1995 and 2005 (infection rates have been relatively steady since then) the Department of Health claims that the rise in infection rates is in part linked to advances in medicine allowing people to live for longer, requiring more major operations, which in turn can lead to infection. Although the number of hospital superbug cases has fallen slightly in recent years, in England and Wales between 2004 and 2008 MRSA was involved in three per 1,000 deaths, while C. diff was involved in one in every 1,000 deaths.

On the rise
What are the other possible causes for the rise in incidents of hospital acquired infections? Patients groups and healthcare professionals blame falling standards of hygiene. A cleanliness survey of England’s 394 NHS trusts by the Healthcare Commission in 2008 found a quarter of all those surveyed failed to comply with hygiene regulations. The commission said 14 per cent of trusts were unable to sign a declaration that they “keep patients, staff and visitors safe with systems to ensure risk of healthcare-acquired infection to patients is reduced” – a failure rate almost double that of an identical survey from 2007.

Following these lines, the public services union Unison blames this situation on the decline in hospital cleaning staff. Since the 1980s, the number of cleaners has almost halved – from 100,000 to 55,000 in 2008/09.

Doctors and nurses have also been accused of failing to always wash their hands between treating patients. The National Patient Safety Agency published a report that found only 40 per cent of necessary hand-hygiene procedures were being carried out in NHS hospitals. Research by the Royal College of Surgeons found that doctors’ neckties were a significant source of cross-contamination among patients.

Other high-risk activities are sharing newspapers with another patient and using the ward telephone. Basic hygiene rules include keeping your hands clean by washing thoroughly with soap and water; keeping cuts and sores clean and covered with a clean dressing until healed; and avoiding contact with other people’s wounds or material contaminated from wounds.

Improving awareness

Earlier this year at their biannual summit, the World Federation of Building Service Contractors (WFBSC) resolved to address these issues and improve awareness of the importance of cleaning within healthcare. A key part of their commitment is that, over the coming months, they will be amassing information from governmental bodies and international organisations regarding the most effective methods to prevent the spread of hospital acquired infections in the community.

By September the WFBSC will create a website communicating evidence and advice on cleaning for health, which aims to be coherent, accessible and supported by the World Health Organization. In this project the WFBSC aims to create a central source of information on cleaning for the control of infection.

Shaping the debate
Meanwhile, the Cleaning and Support Services Association (CSSA) is helping shape the debate on hospital acquired infections, by advising hospitals to take a range of practical steps to manage the risk. The CSSA regularly attends World Health Authority Summits, assisting the framing the debate from a UK perspective and, as the representative of 70 per cent of the contract cleaning industry, feeding member’s views and experience back to international legislative bodies.

The CSSA advises that regular hand washing by all staff, visitors and patients will make a big difference. Bacteria are often spread between patients and the environment on the hands of clinical professionals and patients and good hand hygiene greatly reduces this transmission route. Smarter hospital cleaning makes a real difference to bacterial transmission. The CSSA’s research suggests that superbugs are being spread on items like tables, door handles and telephones– human touch points in the healthcare environment.

The CSSA supports the view that regular screening of patients and staff with quarantine for infected parties is an influence. This is practised in hospitals in the Netherlands and has shown to greatly reduce the instance of MRSA.

The work of the CSSA and the WFBSC project hopes to both guide the cleaning processes in hospitals, and yield answers on a crucial issue. Despite this, the question still remains: is there the political will to enforce their recommendations?

Prevention strategies
With the ever-present threat of outbreaks of the new pandemic strains, it would be very unlikely that a specific vaccine would be available to inoculate the public during the first wave of the pandemic. In addition, depending on the severity of the outbreak, there may not be sufficient quantities of antiviral medications to go around.

This means that governments and councils, through taking on the CSSA/WFBSC’s advice, will have to focus their efforts on the prevention of transmission of the disease within our communities. The case they are trying to build in support of a more robust prevention strategy, one that will save lives and money in the long-term, is hoped to become impossible for governments to ignore.

Using improved methods of prevention, detection and treatment is the only way that our high-density living in urban environments will decelerate transmission of a disease which could have a devastating impact. The role of trade associations in continuing to work together with governments becomes vital as the world of healthcare navigates the challenges that lay ahead.

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