Hospital Infection Control- What Next?

While the importance of implementing robust cleaning practices to prevent Healthcare Associated Infections (HAIs) is widely recognized, there is a need for focus on the specifics, including optimal methods, timing, and locations for cleaning. A renewed interest in removing and monitoring surface bioburden could significantly contribute to the adoption of risk-based practices in hospitals.

Furthermore, a significant challenge arises from the absence of universally accepted standards for cleanliness on hard surfaces within healthcare settings. Defining when a surface is truly ‘clean’ remains a question — specifically, determining the acceptable level of contamination for various surface types in diverse areas, wards, or units to ensure reduced risk of HAI.

Complicating matters is the diversity in methods for sampling hard surfaces, which include culture and identification techniques that are not only varied but also prone to inaccuracy, unreliability, high cost, time consumption, and the necessity of microbiological expertise. Moreover, surfaces are susceptible to a myriad of influences, such as the daily application of cleaning fluids, antimicrobial surface coatings, wear and tear, and the formation of biofilm.

Establishing a set of microbiological standards encompassing common hand-touch sites both within and outside near-patient areas would serve as a valuable benchmark for assessing HAI risk. This standardization would not only benefit infection control and domestic agencies but also provide an early indication of potential outbreaks. Additionally, aging hospitals with poorly maintained fabric and internal fixtures face challenges in cleaning. Cleaning intact surfaces on furniture, fixtures, fittings, and floors is much more manageable than attempting to clean surfaces that are disintegrating. Requesting staff to clean areas that are stained, damaged, torn, scratched, cracked, or non-existent not only diminishes motivation but also creates additional environmental niches for potential pathogens.

Multiple questions persist about the precise methods for surface cleaning, prioritization of cleaning areas, frequency, and the approach needed for clinical spaces housing highly vulnerable patients. Achieving a completely sterile environment is either unattainable or, if achieved through potent microbicides, is short-lived. A concept known as the environmental microbiome is disrupted with every surface cleaning, similar to the disturbance observed in the human gut when patients experience Clostridium difficile overgrowth following antibiotic therapy.

Exposure to powerful disinfectants removes resident flora on environmental surfaces, creating ample space for other microbes to contaminate. These disinfectants selectively eliminate susceptible microbes, allowing only those resistant to the microbicidal effect to persist. The extent and type of recontamination may surpass the initial microbial presence. In contrast, wiping alone, or with water or detergent, is less likely to disrupt the surface ecosystem. Therefore, supporting an environment friendly perspective suggests that the focus should be on routinely removing pathogens from surfaces rather than attempting total eradication.

Surfaces are also influenced by daily applications of cleaning fluids, antimicrobial coatings, wear and tear, and the development of biofilm. Establishing microbiological standards encompassing common hand-touch sites within and outside near-patient areas would serve as a valuable benchmark for assessing HAI risk. This would be beneficial not only for infection control and domestic agencies but also as an early indication of potential outbreaks. Sufficient ventilation, proper plumbing, and effective cleaning are essential to minimize the risk of exogenous infections. The diverse susceptibility of patients to infections adds complexity to the evaluation of various control measures, including cleaning interventions.

While healthcare cleaning has gained global recognition, the individuals performing these crucial tasks often go unnoticed and undervalued. Many receive minimal or no training, lack a structured career framework, and face limited opportunities for advancement compared to other professions. Housekeeping positions, with already limited prospects for progression, are further hindered by language and literacy challenges. The current status of cleaning personnel, marked by lower pay scales and basic conditions, does not adequately reflect the physical effort and personal risks involved in protecting patients from hospital pathogens.

 Cleaners regularly face the risk of injury, poisoning, or scalding from equipment and fluids, as well as the potential for infection from exposure to facilities and occupants with transmissible pathogens. The chasm between the growing emphasis on a clean environment and the social and professional status of those responsible for it has widened considerably. It is crucial to address this imbalance, especially in the face of increasing risks of antimicrobial resistance and untreatable infections. Cleaners are the frontline warriors against multidrug-resistant microbial pathogens.

Has hospital cleaning finally reached a level of maturity, rather than lagging behind more widely recognized infection control measures like hand hygiene? One might hope so. The balance between hand hygiene and cleaning hand-touch sites should be considered equally important, yet domestic duties have not garnered the global attention seen for hand hygiene. Since hands must touch surfaces to function, attempts to maintain clean hands are futile if the surfaces they touch are contaminated. Moreover, validating good cleaning practices is more achievable than sustaining compliance with hand hygiene. Hospital cleaning should not be left to personal discretion; instead, it requires evidence-based surface standards, along with training, regular monitoring, and education for all domestic staff. Recognizing the value of a clean hospital should translate into improved status and corresponding salary scales for cleaners.

There is no denying that antimicrobial chemotherapy and vaccines served as the 20th-century antidotes to infection. However, the 21st century demands a broader scientific approach to infection, focusing on a deeper understanding of pathogen transmission. If we cannot treat infection, our efforts should aim to prevent pathogens from reaching patients in the first place

The intricate array of challenges, ranging from high patient turnover to diverse patient conditions, emphasizes the necessity for robust strategies.

Ensuring infection control in hospitals is vital to safeguard patients, healthcare workers, and the broader community from HAIs. The intricate array of challenges, ranging from high patient turnover to diverse patient conditions, emphasizes the necessity for robust strategies. These strategies encompass established practices such as rigorous hand hygiene, Personal Protective Equipment (PPE) usage, environmental cleaning, surveillance, and the incorporation of cutting-edge technologies like AI and UV disinfection systems. Addressing these challenges involves allocating resources, fostering effective communication, providing continuous training, and encouraging patient involvement.

To thrive in this demanding and rapidly evolving landscape, hospitals must enhance their efficiency, competitiveness, sustainability, and resilience for the future. The question is: How can they achieve this? The key lies in investing in intelligent infrastructure. However, it’s crucial to note that a significant percentage of digital transformation initiatives are unsuccessful. The implementation of smart infrastructure in a singular hospital or network is intricate and comes with diverse rates of success. Hence, transitioning to digitalization plans from theory to practice within the hospital, and having the right partner can significantly impact the outcome.

Keerthana Sundar of Clean India Journal spoke with leading experts to understand the present and future of HIC. Read on: