A review of 80 studies finds that evidence-based research into hospital cleaning practices and the comparative effectiveness of different cleaning methods is uncommon.
About one in 25 US patients acquires a infection during their hospital stay, but a review of published research identified by researchers on the topic of cleaning hospital room surfaces turned up little hard data.
The review, published Monday in the Annals of Internal Medicine, found that a multifaceted approach was best to reduce the risk of hospital acquired infections (HAIs), including hand hygiene practices, antimicrobial stewardship, environmental cleansing and disinfecting. But the review also showed that many of the previous studies about cleaning hospital surfaces has been devoid of evidence-based practices, comparative studies of different cleaning methods, and patient-centered outcomes.
Now is the right time to have a conversation about hospital-borne pathogens, says the lead author of the review, Jennifer Han, assistant professor of medicine and epidemiology and associate healthcare epidemiologist at the Hospital of the University of Pennsylvania.
Jennifer Han |
That's because there has been increased interest in preventative cleaning methods such as environmental cleaning—a complex process that involves cleaning surfaces to remove organic and inorganic materials, followed by disinfecting and ongoing monitoring for effectiveness—over the last year.
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Common HAIs include Clostridium difficile and antibiotic-resistant strains of Staphylococcus aureus and enterococci, but Han credits the 2014 Ebola outbreak for bringing awareness and increased concern to hospital-borne pathogens, HAIs, and cleaning methods. "The Ebola outbreak made more people aware that hospital-borne pathogens can be a serious danger," she says.
Not Just Housekeeping
Han's review focused on hard surfaces such as tray tables, bed rails, and toilets—surfaces touched frequently by both patients and healthcare workers and at risk for contamination by pathogens. The researchers focused on methods used to clean hard surfaces, approaches available to monitor how thoroughly the surfaces have been cleaned, and environmental factors that either help facilitate cleaning or can create obstacles to the environmental cleaning process
Environmental cleaning can be easily confused with housekeeping, but they are very different, says Han. "Environmental cleaning is very important and very complex—and often very much behind the scenes in a hospital…. Hospitals need to emphasize that environmental cleaning is actually part of patient care-- it's not just cleaning rooms."
The review, which was commissioned and funded by the Agency for Healthcare Research and Quality, examined 80 studies, of which 76 were primary studies, and four were systemic reviews. Forty-nine examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges to implementation of different cleaning methods. Of the 80 studies, only five were randomized.
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"There are important gaps in evidence for what's best to clean hospital rooms," she says. Her team found that the evidence in these studies was fairly inconsistent, and thorough analysis of the data around cleaning is rare. "There was a definite surprise how much future research will be needed in this area, both in terms of rigorous comparative effectiveness studies," Han says.
Han was also disappointed by the lack of patient-centered outcomes in the studies and disheartened by the emphasis on surface contamination in each of them. "Most of the data was around pathogens on surfaces, which is really not the best metric. The current data is not around whether the patient is exposed to the pathogens or is colonized [by pathogens]," which would be more telling. Han also criticizes the lack of comparative effectiveness studies between methods.
The Future of Clean?
"What was interesting was that there seemed to be some positive studies around newer technologies for cleaning," she adds. Automated, no-touch modalities, ultraviolet light disinfection and hydrogen peroxide vapor all show promise, she says. So do technologies for monitoring contamination, such as ATB bioluminescence and ultraviolet fluorescent surface markers.
Han believes, however, that there more studies on these newer cleaning methods are needed.
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Han hopes her review will help to formulate better studies on hospital cleaning in the future, and would like to see more studies that are benchmarked around evidence-based healthcare and which have clearer metrics of success for different cleaning methods.
And she hopes to see more healthcare organizations take environmental cleaning seriously.
"Many people not involved in [environmental cleaning] directly see this as something akin to housekeeping—which it's not. It's much more important. It's an important component of reducing HAIs, not just keeping hospitals clean—like hotel rooms, which they are certainly not."
Lena J. Weiner is an associate editor at HealthLeaders Media.