A medical administrator, microbiologist, quality control expert and housekeeping expert discuss hospital cleaning

In a conversation ably steered by Dr Vasundhra Atre, Director, Medical Operations, Medical Strategy & Operations Group, Fortis Bangalore, three panellists discussed the ins and outs of environmental cleaning to bring down the rates of Hospital Acquired Infections (HAIs). Dr Abhimanyu Bishnu, Chief Quality & Excellence Officer, Health City Hospital, Guwahati and Founder & CEO, InnovHealth Services, Arindam Dey Sarkar, Deputy General Manager Hospitality & Service Excellence, Woodlands Multispeciality Hospital Ltd, Kolkata and Dr Manisa Sahu, Consultant Microbiologist & Medical Administration, Ramkrishna Care Hospital, Raipur generously shared their experiences and learnings in this field.

Atre: The focus of healthcare today is on clinical outcomes and patient satisfaction, both of which are very closely connected with hospital hygiene. What exactly do we mean by hospital hygiene?

Bishnu: Hygiene is a broad term that we use both in functional and clinical aspects. If we define it by the Oxford dictionary, it would be certain practices that are conducive to the maintenance of health and prevention of diseases. Hygiene can be cleanliness as well as disinfection.

The healthcare sector has both hospitality and clinical components. It isn’t just aesthetics that matters. When it comes to infection control, we must look at clinical outcomes.

If we look at the different practices that go into hygiene, there is: disinfection, where you decrease the microbial load of the surface of a particular area; cleaning, which is basically the removal of dirt or other material from a surface; and sterilisation, which is not important for surfaces per se but is meant for instruments or other objects that are used for clinical interventions. Fumigation as a procedure is outdated these days.

 

To achieve hygiene, we must remember the acronym WASTE:

W is the workforce. A correctly trained motivated workforce is very important for any kind of healthcare facility.

A is the area, and its level of hygiene and kind of hygiene needed. The hygiene practices that are followed should depend on the type of area; the disinfection level of an ICU cannot be that of a corridor. This is why areas are categorised into high risk, moderate risk and low risk.

S is the surface. High touch surfaces such as door knobs need to be attended to in a concentrated, concerted effort. Hands are the most potent transmitters of infection.

T is for technology. Different types of technology, which includes machines, chemicals and other types of equipment.

 

E is for Equipment: The different kinds of housekeeping equipment we use in healthcare nowadays is becoming more and more automated. The amount of tedious, manual work is going down.

Atre: Can you give us an example of how the hospital environment led to a hospital acquired infection? How do you go about choosing a cleaning chemical to tackle this?

Sahu: When we talk about hospital-acquired infections, Multi Drug Resistant Organisms (MDRO) come to mind. And because they are exposed to various antiseptics and antibiotics, it is very difficult to tackle them.

Among all the standard precautions that we take, hand hygiene is most important, but that is not the only solution. The hospital environment too plays a very vital role.

For example, in my last setup, we had an impending outbreak in our setup with an emerging fungal infection called Candida Oris. We had three cases and the span of the infection was almost four months. When we dug deeper, we found that the first patient was carrying the organism from another institute. After he left the room, the same room was occupied by another patient, who also got the same infection. The second case was followed by a third.

When we did a root cause analysis, we found the cleaning of the hospital was lacking somewhere; there was no other reason for the next two patients to contract the infection. We did a thorough cleaning, and did not encounter any other such cases in that room.

We have high-risk carriers, low-risk areas, and moderate-risk areas, and based on that, we have high-level disinfectants, low-level disinfectants, and intermediate-level disinfectants. If we are talking about OTs and isolation areas, we need a high-level disinfectant. If it is a ward with non-infected patients who are admitted for a non-infectious illness, intermediate level disinfectants like a quaternary ammonium compound are enough.

 

When choosing a cleaner disinfectant, we look at four or five parameters: level of disinfection required, EPA approval, contact duration, method of application and last but not the least, cost.

Bishnu: This would be dependent on whether the technology is right for that kind of setting or not. In a Tier 3 city, you might have a problem with the supply chain of certain disinfectants. Instead of using a highly expensive disinfectant in such a place, you may have to upgrade manpower. In a corporate hospital in a Tier I city, the situation is very different.

Atre: How are the ground level housekeeping staff made aware of and responsible for environmental cleaning?

Sarkar: Every month, we have an infection control meeting in the hospital where we discuss possible infection hot spots, which are graphically represented. Doctors, clinic personnel, lab engineers and housekeeping supervisors are invited to understand the scenario.

If we discuss this just at the board level, it doesn’t percolate down to the housekeeping staff. Hence, we invite the housekeeping team to attend the meeting as hygiene is very important to their health as well. They need to understand what chemicals they should use, how they would use them, and when PPE should be used.

Training starts from the infection control meeting itself. Down the line, there is a separate meeting that is conducted by the housekeeping manager, who understands the entire scenario and then passes on relevant information to his team in layman’s language.

Atre: How important is hospital design when it comes to controlling environmental sources of HAIs? Is there anything that we need to change in the way we’re looking at this today?

 

Bishnu: The dictum of hospital design is, form follows function. We should decide on a process flow, and only then ought to build a hospital. Unfortunately, that’s not how hospitals are built in our country.

The separation of clean and dirty areas and corridors is critical. Covid made us pay attention to air changes and the direction of airflow. In some cases, we had to set up negative pressure rooms.

Atre: We need to look at hospital design from the perspective of the technologies we use for cleaning. For example, even if I have a floor cleaning robot, unless I have got an access control door, I still need somebody to physically open the door for the robot to enter the room. In terms of the design, the flow aspect is very important.

People should be aware that UV light does not even penetrate the paper. So, if I have a paper that comes in front of the UV light, it’s not going to cross it and will not help in sterilisation. In short, if a surface is not exposed, it is not going to get sterilised. Without the man behind the machine understanding the technology, no technology is going to be useful.

At the end of the day, every hospital is looking at ROI. How do you view cleaning from a budgeting perspective?

Sahu: We compare the cost of housekeeping equipment and resources with the cost of a single HAI. If your environmental cleaning is proper, and there is at least a 3% decrease in your HAI rates, the benefit will be reflected in thousands.

Sarkar: When we budget for the year, hygiene protocols as well as the people involved in it are all taken into account. We also keep a place buffer for new technologies that may come in.

Bishnu: I’d like to link it to a broader term called cost of poor quality. Ultimately, there is a cost to not implementing a certain thing. Whether it’s increased length of infections or increased use of antibiotics, it has been demonstrated that not implementing infection control protocols in a hospital is a risky choice.

Sahu: In my last setup, the housekeeping service provider arranged for a third-party audit, which we were not aware of. Across the country, some 17-18 healthcare facilities were audited, and our hospital was ranked first among all the hospitals. We were impressed to know that we matter. Now, our team is even more involved and the infection control activities they perform.