Cleaning and disinfection

practices in the healthcare

environment
ermira.tartari@gmail.com
@ermiratartari

Ermira Tartari
Faculty of Health Sciences, University of Malta, Mater Dei Hospital, Malta
Infection Control Programme, University of Geneva Hospitals, Switzerland
 DISCLOSURES

I have no conflicts of interest to declare

why cleaning and disinfection
in the healthcare environment?
• Healthcare-associated infections prolong
length of hospital stay, increase risk of
mortality and are a burden on healthcare
systems.
• Antimicrobial resistance is a global public
health threat and effective programmes are
needed to reduce the risk.
• The hospital environment is a reservoir for
the transmission of microorganisms that can
lead to healthcare associated infection.
Magill et al. N Engl J Med (2014) 370:1198-208
Zingg et al. Lancet Infect Dis (2015) 15:212-224
Otter et al. Infect Control Hosp Epidemiol (2015)
International health regulations to
combat antimicrobial resistance
(AMR)
Objective 1: Improve awareness and understanding of antimicrobial
resistance through effective communication, education and training
Objective 2: Strengthen the knowledge and evidence base through
surveillance and research
Objective 3: Reduce the incidence of infection through effective
sanitation, hygiene and infection prevention measures
Objective 4: Optimize the use of antimicrobial medicines in human and animal
health
Objective 5: Develop the economic case for sustainable investment that takes
account of the needs of all countries, and increase investment in new
medicines, diagnostic tools, vaccines and other interventions
World Health Organization. Global action plan on antimicrobial resistance. 2015; Available at:
http://apps.who.int/iris/handle/10665/193736.
Otter et al. Infect Control Hosp Epidemiol 2011;32:687-699. Slide courtesy: J Otter
• To assess differences in cleaning and disinfection
practices in healthcare facilities worldwide
• Self-assessment survey with 30 multiple
choice type questions
• Survey tested and piloted
• Decontamination practices:
- Clinical wards
- Operating theatres
Kenters et al. J Hosp Infect 2018;100:236-241.
 33
28
21

1 17
% participating

110 hospitals from 23 countries

who participated in the survey?
 Guidelines

In house employees versus external contractor

Lack of clarity of who should do what (housekeeping/nursing staff)?
• Cleaning and disinfection of shared equipment
• Areas outside of the patient’s room
Education and Training
 Education and Training
Are healthcare workers appropriately trained in
environmental cleaning and disinfection?
1. Unclear individual responsibilities ‘who cleans what’
2. Teaching initiatives may be compunded by time, language
and literacy problems
3. Frequency of training
4. Competency assessment
5. Certification

Anderson et al. J Hosp Infect 2011;78:178-81

Which disinfectants are most commonly used
for disinfection of the patient environment?
The use of innovative products or
equipment in healthcare facilities
 Cleaning frequency of
‘high-touch’ surfaces

• Telephone, door handles, bed rails, bedside table,

nursing call button
• A reservoir for pathogen transmission
• Only 40-50% of surfaces that need to be cleaned are
actually cleaned*
* Carling et al. J Hosp Infect 2010;38:S41-50.
Reusable curtains
Enhanced environmental hygiene
Cleaning and disinfection in the
Operating Theatre
 Are enhanced cleaning practices used after a
patient with a MDRO visits the Operating Theatre?
 Monitoring methods to assess cleaning
and disinfection
Monitoring methods

80%

70%

60%

50%

40%

30%

20%

10%

0%
Visual Fluorescent markers Microbiological tests ATP measurments

Daily Once weekly Once monthly Once every 6 months Yearly Never Not sure Other
 Monitoring methods
• Visual observation was most often used, this
method does not provide with sufficient information
on cleanliness ‘it looks clean’
• The fluorescent marker method provides more
accurate information on whether the cleaning staff
has cleaned the surfaces adequately
• Adenosine triphosphate (ATP) measurement – can
provide information on the cleanliness of surfaces,
difficult to standardize
 Conclusion

• Widely differing global practices in approaches to

environmental cleaning and disinfection
• Evidence-based guidelines – reference standards
• Defining roles and responsibilities
• Defining minimal training requirements for cleaning staff
• Define (high) risk areas
• Frequency and intervals optimizing cleaning and
disinfection schedule
• Recommendations: cleaning, drying and storage of
cleaning and disinfection equipment
• Quality monitoring methods
• ISAC IPC working group
• Andreas Voss
• Nikki Kenters
• Tom Gottlieb
• Infection Control Teams
• Shaheen Mehtar
• Marin Schweizer
• E Huijskens
• Joost Hopman
 Findings

• Microfibre (65%) or cotton (29%)

• Microfibre wipes – more effective in reducing the bioburden of surfaces
• May transfer bacteria to the next surface that is cleaned with the same
wipe

• The washing process is not standardized and/or insufficient to eliminate

micro-organisms present in the wipes
• Laundering practices may affect removal of pathogens from microfibre and
cotton cloths

• Hypochlorite may damage the microfibre cloth, reducing the efficacy of the
cloth
• QATs can bind with cotton, reducing the efficacy of the disinfectants
• Polyester cloth is recommended for use

Sifuentes et al. Am J Infect Control (2013) 41:912-5

Wren et al. J Hosp Infect (2008) 70:265-71
Engelbrecht et al. Am J Infect Control (2013): 41:908-11