Swept under the carpet?

“I mean, just how hard is it to keep a hospital clean?” asked the Conservatives’ election campaign posters in 2005. The answer, as any healthcare cleaning professional will tell you, is ‘very’ – and the Tories’ implied insult to their professionalism and skills has not been forgotten.
    
The question of hospital cleanliness has proved itself far from simply a political hobbyhorse for the opposition party. In the three years since that general election, the incidence of antibiotic-resistant ‘superbugs’ in UK hospitals has risen – and with it, concern over hospital cleanliness, which in the public mind is intuitively linked with healthcare-acquired infections (HCAIs).

The importance of clean
“It’s important to stress that the evidence shows no clear or direct link between HCAIs and hospital cleanliness,” says Dr Liz Jones, Head of Patient Environment at the Department of Health. “However, no matter what the science tells us, the public are likely to keep on thinking that cleanliness in hospitals is important. If patients think a hospital isn’t clean, they’re likely to think [the hospital] can’t do anything else in a hygienic way either.”
    
Dr Jones cites the results of a recent study by the National Patient Safety Agency, showing that 58 per cent of patients rate the cleanliness of the hospital as the most important issue in questions of privacy and dignity: “It’s top of the list by a long way – above high-quality food, single-sex wards or bays, or even private bathrooms,” says Dr Jones.
    
It isn’t just in the minds of the general public that hospital cleanliness matters. Two important legislative shifts in the past few years indicate that cleanliness is currently rising fast up the priority list of the average hospital Trust Board.
    
The first of these is the question of hospital choice, initially set out in the NHS Plan of 2000, and then the subject of Department of Health guidance in 2003. While the choice agenda was originally conceived as a response to waiting times, in practice its focus has been wider: patients now choose hospitals on various factors, but cleanliness is consistently high on the list. A study done by the Picker Institute Europe in 2006 found that a high level of cleanliness is the second most important factor influencing patients’ choice of hospital, while Ipsos MORI research in early 2007 found cleanliness to be second only to waiting times in patient choices.
    
The second legislative shift that has helped to focus the minds of NHS Trust Boards is the 2007 Corporate Manslaughter Act. This allows the prosecution of organisations with a proven ‘gross failing’ in the management of health and safety that results in fatalities. Plenty of Trust Boards are beginning to reassess their health and safety practices in the light of its implications – and with the potential fatality levels associated with HCAIs, this question has a significant overlap with the cleanliness agenda.
    
“No Trust Board can now afford to ignore the issue of cleanliness,” says Carina Bale, Chair of the Association of Healthcare Cleaning Professionals (AHCP). “Whether it’s for reasons of health and safety, staying out of court, or for simple business reasons of attracting more patients, cleanliness ought to be a crucial issue for every single healthcare organisation in England, Wales, Scotland and Ireland.”

HCAIs: the legislative context
In October 2006 the government adopted a code of practice for the prevention and control of HCAIs in England and Wales, and enshrined it in law as part of the Health Act 2006. The ‘Hygiene Code’, as it has become known, is part of Core Standard 21, itself part of the National Specifications for the NHS. Core Standard 21 calls for all parts of a healthcare facility ‘to be kept clean and well-maintained’.
    
Legislation currently progressing through Parliament is set to introduce a new regulatory framework for health and social care in England and Wales. It proposes that for all providers of healthcare there should exist a framework of 18 registration requirements, and one of the 18 will cover the management of cleanliness hygiene and infection control. It requires effective systems to maintain healthcare premises in clean and hygienic conditions, and to prevent and control the spread of infection with regard in particular to any guidance issued by the Secretary of State. As Murray Devine, safety advisor to the Healthcare Commission, points out:
    
“it’s very interesting that this is the only area of the new legislation where the Secretary of State is retaining direct control.”
    
The new legislation will give inspectors the power to impose fines, prosecute, suspend and cancel registrations; Murray Devine calls it “a real wake-up call to Trust Boards across England and Wales.”
    
Wake-up calls are needed, according to Carina Bale: “For all the obligations that surround Trust Boards on this subject, they still pay too little attention to cleanliness. Cleaning has been a low-priority issue for a long time, and even now it’s only slowly rising to the top of the pile. Healthcare cleaning professionals and their managers need support from non-executive directors, and from the chief exec, to help achieve these massive agendas that affect healthcare organisations at the very deepest levels.”
    
Current good practice includes a raft of new technologies and working methods, including steam cleaning and sanitisation. Last year, acute hospitals in England undertook a countrywide ‘deep-clean’, funded by the Department of Health. However, Dr Liz Jones says that no more funding will be available this year for further deep-cleans, and individual Trusts must therefore manage their own deep-cleaning.

New technologies
Happily for Trust Boards, there has never been a better time to focus on hospital cleanliness – at least from a technology point of view. Encouraged by public attention to the issue, many private sector manufacturers and contractors are developing new cleaning technologies to help in the fight against HCAIs.
    
The most widely adopted of the new cleaning technologies is microfibre, a ‘super-mop and cloth’ developed to pick up spores and bacteria more effectively than conventional fibres. However, in the fight against the two most prevalent HCAIs - MRSA and C Difficile - the use of microfibre must be managed extremely closely, as it could prove to be more of a hindrance than a help, according to consultant microbiologist Dr Vanya Gant: “If you don’t have the proper laundry infrastructure in place, a used microfibre cloth can be a haven for bacteria and spores.” It is essential, he continues, to employ proper laundry technology and rigorous cleaning methodologies to prevent microfibre becoming “a chance to shoot yourself in the foot in the battle against HCAIs.”
    
Following on from microfibre, a range of other technologies are being explored, trialled and developed in conjunction with the NHS. These include ATP, a means of swabbing surfaces to detect levels of viable micro-organisms; alcohol hand-gels distributed around healthcare facilities; self-maintaining cleaning robots; automated tunnel disinfection for mattresses and bed frames; and decontamination technologies such as hydrogen peroxide fumigation.
    
Technology itself is not the only answer, however. Government initiatives are also important, as the success of the recent Department of Health campaigns Bare Below the Elbows and Cleanyourhands shows. Many Trusts are keen to investigate measures such as ‘protected cleaning times’, currently being trialled in a handful of UK hospitals. Some Trusts have established 24/7 Response Teams that can handle deep cleaning, terminal cleans on patient discharge, infection cleaning and patient moves. And plenty of Trusts currently undertaking building or renovation schemes are also aware that hospital design may impact on infection rates: single-room hospitals have been shown to demonstrate lower rates of HCAIs.
    
Most healthcare cleaning professionals agree that the fight against HCAIs will not be won by a single technology, a combination of technologies, “or even by just throwing money at it,” says the AHCP’s Carina Bale. “There is no magic bullet. The complexity of the potential solution to HCAIs shows just how complex a science and procedure hospital cleaning really is. To solve this problem we need something from every quarter: some new technology, some money, some Board-level support, some training and some new initiatives from government. Put together with the professionalism and experience of healthcare cleaning professionals, we stand a fighting chance of keeping HCAIs under control in our hospitals.”

The Association of Healthcare Cleaning Professionals
Two years ago, the Association of Domestic Management reinvented itself to become the Association of Healthcare Cleaning Professionals. It was more than a name-change, as Association Chair Carina Bale explains: “There is a massive range of issues facing healthcare cleaning professionals – not just the prevalence of HCAIs but also latest technologies, compliance issues and the need to implement performance indicators across many different initiatives. Cleaning is now very much at the forefront of healthcare organisations’ agendas. Our members have vast experience and knowledge and there was a need to harness this to reflect the professionalism of our members’ work and to respond to the many new challenges.”