Not so long ago, the UK Government ordered a national ‘deep clean’. This prompted a fair amount of debate among experts and the public. If the NHS needed a spring clean, then does that mean that it was dirty in the first place? Perhaps. There does not seem to have been a formal evaluation of impact, but there is some rationale for closing and cleaning wards. For example, this paper from the early 1970s evaluated the impact of closing and cleaning five wards in London.
The five wards (four surgical and one medical) had an outbreak of MRSA (termed ‘cloxacillin-resistant S. aureus’). Rates of infection (termed ‘sepsis’) were monitored on the study wards before and after closing and cleaning. Wards were closed to admissions and emptied of patients. All fabrics were sent for laundering and all left over supplies were discarded. Cleaning comprised washing floors, walls and all other surfaces with hot water containing detergent; bed frames and furniture were also washed. The length of time that all this cleaning too is not specified, but I suspect it took place over several days. Crucially, staff and patients were screened for carriage of epidemic strains of S. aureus; colonised patients were not re-admitted after ward cleaning where possible.
The charts below show the impact on all infections (Figure 1), all S. aureus infection (Figure 2) and MRSA infection (Figure 3). Infection rates were compared 3 months before vs. 3 months after cleaning on Wards 1-3 and 6 months before vs. 6 months after on Wards 4 and 5. As you can see, the impact was pretty dramatic.
Figure 1. Total infection rate (proportion of admissions infected) on the five wards before vs. after ward closing and cleaning.
Figure 2. S. aureus infection rate (proportion of admissions infected) on the five wards before vs. after ward closing and cleaning.
Figure 3. MRSA infection rate (proportion of admissions infected) on the five wards before vs. after ward closing and cleaning.
The poor reduction in total infection rate on Ward 1, a gynecological ward, (Figure 1) is largely due to high Gram-negative infection rates before and after cleaning, most likely explained by endogenous urinary tract infections. Reductions in total infection rate and S. aureus infection rate appeared to be less on Wards 4 and 5, which could be influenced by the fact that rates were compared for 6 months pre and post ward closing and cleaning rather than 3 months on Wards 1-3. The impact of a one off environmental intervention is likely to diminish over time. It’s also interesting to note that the MRSA infections identified on Ward 5, a general surgical ward, after cleaning were due to a different strain of MRSA (determined by phage typing and antibiogram) than before cleaning. This new strain matched the outbreak strain from Ward 2. Two of the patients on Ward 5 who became infected with this strain were operated on in the same theatre as the infected patients from Ward 2 within two weeks of one another. Four other patients (on different wards) also appeared to acquire the strain in the same operating theatre.
The study has several important limitations. It is not possible to be certain whether active screening and isolation or ward closing and cleaning were responsible for the reduction in infection rates; it was probably combined impact. The study design lacked the rigor of more modern investigations: infection rates were not expressed in terms of patient-days and infection rates were compared for different time periods making direct comparison of the impact across the five wards difficult. Also, no environmental sampling was conducted to demonstrate the efficacy of the cleaning procedure (both initially and in terms of recontamination).
Notwithstanding these limitations, the study provides evidence that ward closing and cleaning combined with active screening and selective readmission resulted in a dramatic reduction in the rate of nosocomial infection on five study wards. The impact appeared to be most pronounced in the first three months, which is consistent with a reduction in environmental contamination. Outbreaks of MRSA were eradicated by closing and cleaning on all five study wards. However, there was evidence of new nosocomial transmission following the re-admission of infected patients. Finally there was some interesting circumstantial evidence of transmission within operating theatres.
Article citation: Noone P, Griffiths RJ. The effect of sepsis rates of closing and cleaning hospital wards. J Clin Pathol 1971;24:721-725.
Reflections on Infection Prevention and Control 
Thanks for the interesting article Jon. Is there a possibility that these reductions, impressive as they are, were down to implementing screening and decolonization rather than the closing and cleaning of the wards?
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A key question Sam, thanks. Due to the somewhat ‘pragmatic’ study design you can’t be sure whether a) all of the reductions were due to implementing screening and decolonization, b) all of the reductions were due to closing and cleaning the wards or c) it was a combination of the two. There is evidence elsewhere that both screening & decolonization and closing & cleaning wards can help to reduce the transmission of S. aureus, so a combination of the two seems most likely. The fact that the reduction measured on the wards that were evaluated for a shorter period of time was greater argues for the importance of closing and cleaning the wards. Put another way, you’d expect the impact of a one-off closing and cleaning of the wards to diminish over time. It’s a shame that the data were not reported by month, which would have helped to investigate this idea.
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Question – if a hospital find out a patient has MRSA, and if they could track which rooms/hallways the patient had been in, as well as which patients/staff had been in contact with that patient, and in turn what rooms they had been in… would the hospital still choose to clean the entire ward, or would it be reasonable to only clean the affected areas?
The hospital wouldn’t be tracking MRSA, but the patient — and the staff members who come into contact with that patient. A hospital using a Real-time Locating System (RTLS) with both patients and caregivers wearing badges would be able to “see” where the patient had been, who they had come into contact with, etc. While we see RTLS most often used for asset tracking, few hospitals take the next step to badge patients and caregivers. I’m wondering just how valuable this kind of data is for infection control, and if this could spur further use of the technology.
I work for an RTLS/RFID vendor, and we actually have an “Exposure Report” you can run to see where an infectious patient has been, who he has come into contact with, etc. I think we need to do a better job of getting the word out that this technology exists – especially in today’s healthcare environment where HAIs are such a major concern.
For anyone interested: http://www.versustech.com/rtls-benefits/infection-control/
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That sounds like a really interesting idea, and one that is well worth exploring further. One of the pitches at the ICPIC innovation academy was along these lines; here’s an extract from my conference report blog:
‘”Combining electronic contacts data and virological data for studying the transmission of infections at hospital.”’ Tagging patients and staff with RFID badges to track movements and then trace proximity (though not contact per se). Useful Harry Potter “Marauders’ Map” style technology.’
Emptying wards for deep cleaning is rarely feasible so the best we can do is target environmental interventions towards areas most likely to be contaminated, primarily rooms used to care for patients with MRSA. It sounds like RTLS systems may be helpful with this.
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I would offer a simpler and less costly method than tracking patients (who might object to being tracked as an invasion of privacy and heaven knows they lose enough privacy, dignity and independence as it is) or shuttering whole wards for deep cleaning.
If hospitals truly were concerned with decreasing the number of HAIs, improving patient outcomes, improving their image and attractiveness to the patient pool and public, and increasing the bottom line they could do these simple steps:
1. Institute standardized checklists for processing all rooms, including operating rooms.
2. Staff the Environmental Services department with sufficient trained personnel to provide quality service to each and every patient.
3. Allow the Environmental Services staff sufficient time in each room (25-30 minutes for occupied rooms and 45-60 minuted for discharges).
4. Forget about the number of square feet allocated to each hygiene specialist and look to patient census and the true amount of time needed to provide quality results when processing patient rooms. Square footage is good for hallways and gymnasiums but not patient rooms.
5. Make the investment in providing proper equipment, including microfiber or micro denier infection prevention textiles, proper staff carts, and proper disinfectants. As it is, many, many Environmental Services departments have such a diminished budget that they must resort to using discarded wash cloths and other cotton terry cloth products, antiquated “janitors” carts that do not meet the security requirements of CMS or TJC, and the lowest cost, least effective disinfectant cleaners.
6. Provide sufficient training and education to the staff so they understand the “why” of what they are doing and the “how” to carry out the proper processes.
If hospitals viewed the professionals in Environmental Services with the same respect and regard as they do other healthcare professionals and provided the support to the management and staff, shutting down whole wards would be unnecessary and everyone would benefit.
It never ceases to amaze me that the hospitality industry (hotels) assigns between 10-14 rooms per housekeeper per day but healthcare typically assigns 20+ rooms per hygiene specialist per day and that does not count the public areas they are required to process. Yet healthcare expects hygienically clean rooms from their staff? The law of Diminishing Returns has been proven true for decades, yet is is ignored by healthcare. Why?
We can track the patients all day long to see where they’ve been and have all of the retrospective metadata analysis all we want, but that will still reinforce a reactive (or is inactive a better term?) “lead from behind” mentality that affects healthcare today. Why not be proactive and get in front of HAIs and stay in front of HAIs. Reactive rather than proactive is detrimental to patients and a waste of lives and money.
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Why do hospitals not follow up cleaning by coating surfaces with TiO2?
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I am interested in the potential benefits of antimicrobial surfaces such as TiO2, but there are several issues that preclude widespread adoption, including: lack of evidence of microbiological and clinical impact in the healthcare setting, the need for activation by UV light for some TiO2 formulations and questions over cost and durability.
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