Today was the inaugural Healthcare Cleaning Forum. The plan was to showcase some healthcare cleaning and disinfection science at the Interclean Conference in Amsterdam (which is a huge general cleaning show). I think we managed to create some awareness about the unique challenges of cleaning and disinfection in healthcare outside of the usual crowd.

Didier Pittet kicked off, finding that 90% of the audience agreed that there’s a gap between the healthcare and cleaning industry (hence the need for this initiative!). Didier drew a parallel between the successful global campaign to improve hand hygiene and the need to improve environmental hygiene. Hands are really just another highly mobile surface in healthcare that are commonly contaminated and rarely disinfected.

Pierre Parneix discussed the evidence supporting the role of the contaminated environment in the transmission of pathogens that can cause HCAI. Good old ‘Vomiting Larry’ featured prominently to evidence that contamination goes everywhere, it’s difficult to get rid of, and cleaning staff readily self-contaminate. Pierre presented hospital cleaning as a performance sport: excellence requires skill, training, dedication, and investment.

Andreas Voss described the need for a different view on hospital cleaning and disinfection, as a vital component of infection prevention (and not a Cinderella service). There’s some interesting evidence (here and here) that outsourcing is bad for the quality of hospital cleaning and disinfection. Andreas made a powerful case for a new profession of certified hospital cleaners; the transition would be challenging, costly…and thoroughly worthwhile! Achieving high standards of hospital cleaning and disinfection requires the modification of human behaviour (as does other basic IPC practice and antimicrobial stewardship): both good practice and bad practice are transmissible agents.

Andreea Moldovan highlighted the vital importance of education, training, and communication for all involved in hospital cleaning and disinfection (from the ward cleaner to the CEO). An effective training programme should be more carrot than stick (to build trust and motivation), aim to flatten hierarchy, and be informed by information from the real experts: those who are actually doing the cleaning at the coal face.

I gave a talk on about the cost and value of hospital cleaning and disinfection (you can download the slides here). It was a tall order: there is scant data on the cost-effectiveness of cleaning and disinfection. There is pretty good data exploring the economic impact of HCAI and AMR (with the overall burden likely to be measured in trillions by 2050 if we don’t change the trajectory). But, whilst there is now strong data that cleaning and disinfection is effective in improving patient outcomes, there is limited cost-effectiveness data. Perhaps the best example is a study from 2009 by Stephanie Dancer showing that an additional cleaner reduced MRSA infections by 27% and saved somewhere between £30,000 and £70,000 (Figure 1). The caveat here is that it can be difficult to work out exactly where ‘savings’ from reduced HCAI appear in hospital finances, since they are a mixture of reduced fixed and variable costs.

Figure: The cost-effectiveness of hospital cleaning (MRSA). The impact of an extra cleaner was modelled in a 12 month ward cross-over study. The cleaner cost £12k per year, and each MRSA infection was assumed to cost £9k.

Finally, since Markus Dettenkofer was unable to make it (we missed him!), Andreas and I shared his session on new frontiers of research and innovation. Andreas covered ways to improve existing mechanisms of cleaning and disinfection, as well as some ‘out there’ approaches, not least creating a ‘water free’ ICU to prevent the transmission of Gram-negative bacteria (which seems to be very effective). Andreas gave the example of a study where human operators were able to clean hospital beds to the same standard as automated washers, but that this was not sustainable (when nobody was watching). This paved the way for my thoughts on automated room disinfection: these systems don’t replace conventional cleaning and disinfection but are an effective adjunctive measure to improve the quality of disinfection and enhance patient safety.

I was pleased to be able to contribute to this event, to help to bridge the gap between cleaning and IPC professionals.