Brett Mitchell and colleagues have just published the exciting findings of the Researching Effective Approaches to Cleaning in Hospitals (REACH) study in the Lancet Infectious Diseases, along with my editorial. This large 11-centre randomised intervention study found that a low-cost enhancement to environmental hygiene managed to significantly reduce VRE infections, but did not reduce S. aureus bacteraemia or C. difficile infections.
The study was a multi-centre stepped-wedge randomised controlled trial, performed in 11 Australian hospitals between May 2016 and 2017. The intervention tested in this ambitious study was a systematic bundle of interventions to improve environmental hygiene, targeting both routine daily cleaning and cleaning / disinfection at the time of patient discharge. This involved a review of the environmental hygiene approach in each hospital, and a structured, tailored set of recommendations to improve product choice, technique, audit, training, and communication of performance. A unique aspect of the intervention was to raise the profile and importance of cleaning, support a culture shift in the perception and profile of environmental hygiene staff, and to encourage daily contact between environmental hygiene staff and ward leaders or managers.
There was a 37% reduction in VRE infections (from 0.35 to 0.22 per 10,000 occupied bed days (RR 0.63, 95% CI 0.41–0.97, p=0.0340), but no significant changes in the incidence of S. aureus bacteraemia (0.97 to 0.80/10,000 occupied bed days; RR 0.82, 95% CI 0.60–1.12, p=0.2180) or C. difficle infection (2.34 to 2.52/10,000 occupied bed days; RR 1.07, 95% CI 0.88–1.30, p=0.4655). Importantly, there were no noticeable changes in hand hygiene compliance or antimicrobial use during the study period.
The intervention was a mixture of training, education, small policy changes, and some ‘organisational encouragement’ to increase the status of environmental hygiene and environmental hygiene staff. And or all of these changes could have resulted in the reduction of VRE – and it seems likely that all contributed, but perhaps some elements of the bundle were redundant?
The study also measured the performance of cleaning using fluorescent markers. The removal of markers improved significantly in bathrooms (from 55% to 76%) and in bedrooms (from 64% to 86%). It’s a shame that the authors did not correlate the removal of these fluorescent markers with the rate of HCAI, which would have worked nicely within the stepped-wedge design. Perhaps they’re saving this for a subsequent paper?
The big question raised by this study is why there was a reduction in VRE infections, but not in S. aureus bacteraemia or C. difficile infections. In the case of S. aureus bacteraemia, a series of national interventions in Australia had made an impressive impact on S. aureus bacteraemia prior to this study. This could mean that the transmitted portion of cases may have already been largely addressed leaving mainly S. aureus bacteraemia with an endogenous source, which are not going to be touched by an environmental hygiene intervention. Also, the study did not evaluate the acquisition of colonisation, which would be a more sensitive indicator of impact for S. aureus. The fact that C. difficile infections were not reduced by enhanced cleaning is more surprising, on the face of it. However, when you look in detail at the intervention, there wasn’t a systematic focus on the appropriate use of a sporicidal disinfectant for environmental hygiene related to C. difficile. This suggests that we need to…ahem…reach further than the intervention tested in this study in developing enhanced environmental hygiene measures to tackle C. difficile.
This is an important and timely study, which underlines both the importance of environmental hygiene in preventing HCAI and also highlights our knowledge gaps around how what an effective environmental hygiene intervention looks like. The study is well-designed and well-executed, and would have been a huge undertaking to deliver operationally. This study should prompt us all to review and optimise our environmental hygiene policies and protocols!