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  3. Hospital Cleaning 窶・role of microcloths in decontaminating the hospital environment

Hospital Cleaning 窶・role of microcloths in decontaminating the hospital environment

Hospital acquired infections still pose a major problem and a substantial risk to patients (Dettenkofer and Spencer (2007). Cleaning and disinfection are amongst the preventative measures to reassure staff and patients that they are not put at risk (Dettenkofer and Spencer 2007). Effective hospital cleaning is essential for the quality of patient care and it enhances the patient’s experience. The general public associate visibly dirty wards with increasing rates of MRSA (Dancer (2008).

Many of the organisms that are associated with Health Care Associated Infection (HCAI) can withstand the rigours of the hospital environment (Dancer 1999). Rampling et al (2001) demonstrated in their systematic review that MRSA and other pathogens can live in the environment for three months to around five years. French et al (2004) supports these findings, and notes their controlled trial that MRSA still persisted even after terminal cleaning. One of the most robust pathogens is Clostridium difficile, which is an anaerobic gram positive rod which is linked to antibiotic resistant colitis. It forms a spore that can withstand extreme temperatures, drying and the majority of hospital disinfectants. Wilcox et al (2003) suggests the spore persists in the environment for months and that it is resistant to many cleaning agents.

Cleaning has not been regarded as an evidenced based science and therefore receives little attention from the scientific community and as Dancer (2002) points out it is very difficult to identify any evidence that supports cleaning and the eradication of pathogens. Boyce (2007) identified that cleaning or disinfection of the environment can reduce the rate of transmission of the pathogens, a point supported by Rutala et al (2007) and White et al (2007).

Although detergents and disinfectants under certain conditions are important measures for maintaining a clean environment they do contribute a cost to the health service. Using disinfectant agents presents its own problems as micro biocides contain oxygen releasing compounds such as peroxides or ammonia, which are harmful to health (Thorsteinsson et al 2003), and there is a growing body of evidence that there is a possible link between using detergents and antimicrobial resistance. (Boyce 2007, Fraise 2007, Russell 2003, Russell 2002).

There have been many recent developments in environmental cleaning, and it is important that healthcare facilities find new ways to improve cleanliness so that it does not just alleviate staff and the public’s concern over infection, it has positive implications for morale, shortened patient length of stay, reduce cross infection and overall improve the delivery of healthcare. Over the past few years traditional cleaning methods have been challenged and replaced with new approaches: steam cleaning, microfibre and hydrogen peroxide.

Microcloths

Microfibre cloths have recently been introduced into the UK and many other countries and have demonstrated to be more effective at surface cleaning in hospital wards (Hamilton et al 2010, Wren et al 2008, DOH 2007, ADM 2004). Microfibre has been in circulation since the nineteen nineties and is said to be environmental friendly. The microfibres are derived from spherical fibre and are made from larger synthetic fibres of polyester which absorbs grease and dirt, also a polyamide which absorbs water (Nilsen et al 2002). These fibres are approximately one sixteenth the size of a human hair and have forty times more surface area than that of a cotton fibre used in a traditional mop (Rutala et al 2007). The density of the material allows it to hold six times as much water as the traditional mop. The cloth removes particles by a combination of static attraction and capillary action (Hamilton et al 2010). The fibres are positively charged whereas dirt which includes microbes and shed cells from patients and staff on the floor are negatively charged then the particles are attracted to the map (Polonsky and Roill 2004).

There is very little research available regarding the use of the microfibre mop, however, the DoH (2007) published a report regarding the implications and benefits of an integrated approach to cleaning by using the microfibre method and steam cleaning. A recent report quoted by Gant et al (2007) confirmed that cloths from microfibre outperformed traditional cloths in their ability to remove bacteria. This is supported by Wren et al (2008), who in a study of different hospital surfaces were steam cleaned first, ultramicrofibre cloths and the conventional J-cloth were trialled. All surfaces were intentionally contaminated and to demonstrate ‘real life’ were re contaminated every two hours with a selection of bacteria. The results demonstrated that the ultramicrofibre cloths were superior in removing bacteria which often leads to complete removal.

Nielsen et al (2002) discuss the advantages of the microfibre system as being more environmentally friendly rather than taking an infection control perspective. It will reduce staff’s exposure to cleaning agents and reduce the consumption of water and cloths. Rutala et al (2007) demonstrated that the microfibre mop was superior in removing microbes using a detergent cleaner compared to the traditional loop mop. However it was identified that when the microfibre mop used a disinfectant there was no improvement than using a detergent whereas the loop mop was superior with a disinfectant.

Desa et al (2003) advocates the use of the microfibre system, it identified many health and safety benefits such as reducing the exposure to chemicals. Polansky (2004) again in favour of the use of the microfibre system, notes many benefits including being used as an infection control measure. However from their study it does not explain how these findings have been produced or how the study was conducted. It explains that clean water was used for each patient along with a new microfibre mop for each patient. There is no justification to how they accounted for the results for example there is no visual assessment or microbiological count.

Bergen et al (2009) tested the hypothesis that microfibre cloths spread bacteria when they are used to cleaning. It was a controlled experiment and surfaces were contaminated by two types of bacteria, the microfibre cloths were folded sixteen times and cleaned several sterile surfaces. On visual examination the surfaces were visibly clean on inspection it was verified that there was a reduction the microbial count on the contaminated surfaces, however bacteria had spread to the sterile surfaces via the microfibre cloths. This has implication for microbes such a MRSA which can adhere to the microfibre cloth. However this experiment took place in a laboratory and not in a clinical ward.

The main disadvantage of microfibre is that it cannot be used with chlorine based disinfectants. Disinfectants reduce the microbial load as previously discussed, Hamilton et al (2007) compared the effects of ultramicrofibre cloths with water and a copper based biocide solution. It was trialled in four working clinical environments, lasting seven weeks. The data was analysed blind to ensure validity. It was demonstrated that cleaning with ultramicrofibre and a copper based biocide significantly reduced the microbial count. These findings are supported by Gant et al (2007); who advocate the use of a copper based biocide with microfibre. The study verified that it was active against the hardy spores of Clostridium difficile, and demonstrated that when the mops were stored at room temperature the mops contained no viable microbes.

Much of the research availed demonstrates the environmental friendliness of microfibre, there is some discussion surrounding infection control. However the introduction of microfibre comes at a cost to the organisation. Lehman (2004) discusses the advantages of the system but also the cost. The initial costs can be daunting especially in today’s cash strapped organisations. The Environmental Protection Agency (EPA) (2002) points out that the microfibre mop costs three times as much as a traditional mop, whereas the microfibre mop lasts longer and savings will be seen in the long term. The DoH (2007) supports this explaining that a capital investment would be required to introduce this into any organisation; the largest outlay would be for laundry services.

The importance of environmental cleaning has debated the use of detergents and disinfectants. It has been discussed that the microfibre is superior to traditional methods nonetheless it has been explained that cleaning is effective using both methods when a biocide is used.

There is limited quality literature available regarding the use of the microfibre system, there requires more scientific evidence and these need to be in controlled conditions especially where a quantitative approach can be taken (Moore and Griffiths 2006). Many of the studies examined are sponsored by companies that produce and sell microfibre fibres so it could be argued that these results need to be considered with some caution. Moore and Griffiths (2006) make a valid point that microfibre should not necessarily mean a superior cleaning product in relation to the traditional mop and bucket. As Dancer (2009) points out until cleaning becomes evidence based science the importance of a clean healthcare environment will always be speculative.

REFERENCES

Association of Domestic Management (ADM) (2004). The impact of microfiber technology on the clearning of healthcare facilities. Wylam. Northumberland.
Ballerman C.A.J.M., Block H.E.M., Swennenhuis J., Troeltra A., Mascini E>M> (2003). Dry cleaning or wet mopping: Comparison of bacterial colony counts in the hospital environments. Journal of Hospital Infection. 53, 150 窶・152.
Bergen L.K., Meyer M., Hog M., Rubenhagen B., Anderson L.P. (2009) Spread of bacteria on surfaces when cleaning with mirofibre cloths. Journal of Hospital Infection 71, 132-137.

Boyce J.M. (2007) Environmental contamination makes an important contribution to hospital infection. Journal of Hospital Infection. 65, 50-54

Dancer S. (2009) The role of the environmental cleaning in their control of hospital-acquired infection. Journal of Hospital Infection. 73. 378-385

Dancer S. (2008). Importance of the environment in Methicillin resistant Staphylococcus aureus acquisition: the case for hospital cleaning. Infection. The lancet.com. 8, 1001-113

Dancer S. (2002). Hospital acquired infection: is cleaning the answer? CPD Infection. 3,2, 40-46.

Dancer S. (1999). Mopping up hospital infection. Journal of Hospital Infection. 43, 85-100

Desa J., Bello A., Galligan C., Fuller T., Quinn M. (2003). Case study are mops beneficial for hospital . Sustainable Hospitals Projects. Feb.

Dettenkofer M., Spencer R.C. (2007). Importance of environmental decontamination 窶・a critical view. Journal of Hospital Infection. 65, 52, 55-57.

Department of Health (DOH) (2007). An integrated approach to Hospital Cleaning: Microfibre Cloth and Steam Cleaning Technology. DH London.

Environmental Protection Agency (EPA) (2002). Using Microfibre Mops in Hospitals. Nov.

Fraise A.P. (2007). Decontamination of the environment. Journal of Hospital Infection 65, 58-59

French G.L., Otter J.A., Shannon K.P., Adams N.W.T., Wattling D., Parks M.J. (2004) Tackling contamination of the hospital environment by methicillin-resistant Staphlococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. Journal of Hospital Infection. 57, 31-37

Gant V.A., Wren M.W.D., Rollins S.M., Jeans A., Hickok S.S., Hall T.J. (2007). Three novel highly charged copper based biocides: safety and efficacy against healthcare-associated organisms. Journal of Antimicrobial Chemotherapy. 60, 294-299.

Hamilton D., Foster AS., Ballantyne L., Kingsmore P., Bedwell D., Hall TJ., Hickok SS., Jeanes A., Coen P.G., Gant V.A. (2010). Performance of ultramicrofibre cleaning technology with or without addition of a novel copper-base biocide. Journal of Hospital Infection. 74, 62-71.

Moore G., Griffith C. (2006). A laboratory evaluation of the decontamination properties of microfibre cloths. Journal of Hospital Infection. 64, 379-385

Nilsen S.K., Dahl I., Jorgenson O., Schneider T. (2002). Microfibre and ultramicrofibre cloths, their physical characteristics, cleaning effect, abrasion on surfaces, friction and wear resistance. Building Environment. 37 1373-1378

Polonsky D (2004). Should you microfiber? Healthcare Purchasing News. May 40-43

Polonsky D., Roill J.D. (2004). Old Mops Die Hard. Should you Microfibre for infection Control’s sake? Infection Control Today. 07

Rampling A., Wiseman S., Davis L., Hyett A.P., Walbridge A.N. Payne G.C., Carnaby A.J. (2001). Evidence that hospital hygiene is important in the control of Methicillin-resistant Staphylococcus aureus. Journal of Hospital Infection. 49, 109-166.

Russell A.D. (2003) Similarities and differences in the responses of micro-organisms to biocides. Journal of Antimicrobial Chemotherapy. 52, 750-763

Russell A.D. (2002). Biocides and pharmacology active drugs as residues in the environment: is there a correlation with antibiotic resistance? American Journal of Infection Control. 30, 495-498

Rutala W.A., Gergen M.D., Weber D.J. (2007). Microbiologic evaluation of microfiber mops for surface disinfection. American Journal of Infection Control. 35, 569-573

Thorsteinsson T., Loftsson T., Masson M. (2003) Soft antibacterial agents. Current Medicinal Chemistry. 10, 13, 1129-1136.

White L.R., Dancer S.J., Robertson L. (2007). A microbiological evaluation of hospital cleaning methods. International Journal of Environmental Health Review. 17, 4, 285-295.

Wilcox M.H., Fawley W.N., Wigglesworth N., Parnell P., Verity P., Freeman J. (2003), Comparison of the effect of detergent versus hypochlorite on environmental contamination and incidence of Clostridium difficile Infection. Journal of Hospital Infection. 54, 109-114

Wren M.W.D., Rollins M.S.M., Jeans A., Hall T.J., Coen P.G., Grant V.A. (2008). Removing bacteria from hospital surfaces: a laboratory comparison of ultramicrofibre and standard cloths. Journal of Hospital Infection. 70,2.

Related Reading

De Lorenzi S., Finzi G., Parmiggiani R., Cugini P., Cacciari P., Salvatorelli G. (2006) Comparison of floor sanitation methods. Journal of Hospital Infection. 62, 346-348.

Dharam S., Mauaiga P., Copin P., Bessmer G., Tschanz B., Pittet D (1999). Routine disinfection of patient’s environmental surfaces. Myth or reality. Journal of Hospital Infection. 42, 11-117

Exner M., Vacata V., Dietlein E., Gebel. (2004). Household cleaning and surface disinfection: new insights and strategies. Journal of Hospital Infection. 56, S790-S75

Griffith C.J, Cooper R.A, Gilmore J., Davies C., Lewis M. (2000). An evaluation of hospital cleaning regimes and standards. Journal of Hospital Infection. 45, 19 窶・28.

Hardy J.K., Oppenheim B.A., Gossain S., Gao F., Hawkey P.M. (2006) A study of the relationship between environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and patients’ acquisition of MRSA. Infection Control and Hospital |epidemiology. 27, 127-132.

Lehman, D (2004) Microfibres macro benefits. Health Facilities Management Jan 窶・24 -26

Malik E.M., Cooper R.A. Griffiths C.J. (2003). Use of audit tools to evaluate the efficacy of cleaning systems in hospitals. American Journal of Infection Control. 31, 181-187.

Mears A., White A., Cookson B., Devine M., Sedgwick J., Phillips E., Jenkinson H., Bardsley M. (2009) Healthcare-associated infection in acute hospitals: which interventions are effective? Journal of Hospital Infection. 71, 307-313.

Rutala W.A., Weber D.J. (2004). The benefits of surface disinfection. American Journal of Infection Control. 32, 226-231

Rutala W.A., Weber D.J. (2001). Surface disinfection should we do it?Journal of Hospital Infection. 48, (Supp A), S64-68

Jg/2010

University of Wales
Dr. John Gammon
Profile


Dr Gammon is recognised as an international authority on infection prevention and control. Currently, he is a Non -Executive Director of Carmarthenshire NHS Hospital Trust and Deputy Head of the School of Health Science, at Swansea University, Wales, UK. He has practiced as an infection control practitioner for many years and been instrumental in Wales in establishing infection control services. Furthermore he has lead on the establishment infection control courses, and national guidance on hospital and community infection prevention strategies. He has been central to the development of, evidence based, international guidance on patient isolation. His research interests include patient isolation, standard precautions and hand decontamination. He has published a number of research papers and continues to advise the Welsh Government on infection control practice and strategy. He acts as key advisor to a number of commercial companies involved in infection control. His focus of academic interest for the last few years has been the education and professional development of practitioners and specifically infection control practitioners. This has included e-learning course as well as Masters programmes in infection control.