Lesley Lack, BSc (Hons) Nursing Studies, RN, Dip Research.
Ward SisterA study carried out by the Dorset County Hospital infection control team, which had been monitoring the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and collecting microbiological data in one ward for more than two years, identified an environmental strain of MRSA as a causative factor in the increase of postoperative infections (Rampling et al, 2001). As a result, domestic cleaning resources were increased, and the need for a post specific to the cleaning of clinical areas and equipment was recognised as necessary to maintain optimum environmental cleanliness.
A study carried out by the Dorset County Hospital infection control team, which had been monitoring the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and collecting microbiological data in one ward for more than two years, identified an environmental strain of MRSA as a causative factor in the increase of postoperative infections (Rampling et al, 2001). As a result, domestic cleaning resources were increased, and the need for a post specific to the cleaning of clinical areas and equipment was recognised as necessary to maintain optimum environmental cleanliness.
The role is unique in this trust. It does not include any of the standard housekeeping responsibilities such as giving out patients' meals, being responsible for linen or other domestic duties. The post-holder is responsible to, and directed by, the ward sister according to the clinical housekeeping and cleaning needs of the ward area.
The ward environment
The male surgical ward has a fairly modern design because the hospital was built in the 1980s. It has 37 beds and is divided into five bays, each containing six beds, and seven single rooms. Three of the rooms are designated isolation cubicles located in a separate area at one end of the ward with en suite facilities and a dedicated sluice, while the other four rooms are spread throughout the ward between bays, and are also used to nurse infected patients requiring isolation.
Ward patients are predominantly male, with an age range of 70-79 years, about 30% of whom are undergoing urological surgery.
Staphylococcus aureus is a coagulase-positive organism carried by 30-50% of the healthy general population on parts of the body such as the nose, throat, axillae and perineum, with no ill effects (Gould, 2001). Mutations of this bacterium that have become resistant to methicillin, flucloxacillin and a number of other antibiotics, are known as methicillin resistant and have become endemic in Western countries (Benbow, 1998; Dancer, 1999).
The bacteria can spread through direct contact with patients or staff, through infected dust or from contact with infected surfaces. It is well recognised that some organisms can survive in the hospital environment for a long time, leading to an escalation in nosocomial infections, and increasing the risk of infection and subsequent delayed healing in surgical or traumatic wounds (Parker, 1999; Grimble et al, 2001). Indeed, in a hospital that has insufficient cleaning services the level of potential pathogens in the environment is known to increase (Dancer, 1999), adding a growing economic burden of having to treat patients with hospital-acquired infections (Plowman et al, 2001).
MRSA is an acknowledged continuing problem in the current health-care environment, and the constant challenge to eradicate it remains ongoing (Gammon, 1998; Gould, 2001). For patients undergoing surgery, there is also the risk of a fatal outcome as a consequence of having a systemic infection. Following a national survey in Wales in 1997, it was demonstrated that the incidence of MRSA is higher in elderly people, and that men have a higher rate of infection than women (Morgan et al, 2000). A study of patients undergoing urological surgery by Matsukawa et al (2001) confirmed a high incidence of surgical site infections through MRSA.
The microbiological and observational study carried out in the ward for more than two years emphasised the need for a combination of measures to combat any increase in such infections, and reduce the incidence of MRSA (Rampling et al, 2001).
Initial action to tackle the incidence of MRSA
These findings prompted the instigation of domestic cleaning of ward areas. In addition, after obtaining verbal consent, all patients admitted to the ward were swabbed for MRSA status: elective surgical patients were swabbed in the pre-clerking clinic seven days before admission, and emergency patients were swabbed on admission to the ward.
Patients identified as having an MRSA infection before admission were nursed in isolation, in line with standard precautions, and the appropriate MRSA treatment given according to the site of infection, and the type and urgency of the surgical procedure to be carried out. Emergency admissions who were later identified as having MRSA were moved to a single room, and all patient contacts in their bay were reswabbed. On discharge, all patients were swabbed again, thus allowing for the identification of either prior infection or infection acquired in hospital. Environmental swabs of the ward area - from air vents, radiators, door handles, catheter stands and pumps - were collected at regular intervals by the infection control team.
These two strategies revealed that the presence of environmental MRSA varied, and that this dropped when extra cleaning time was allocated to the ward. However, owing to the increasing incidence of MRSA in the general community, and the admission of patients with a surgical emergency whose infection had not been previously identified, it was recognised that it would be extremely difficult to eradicate MRSA completely.
The implementation of these strategies did, however, considerably increase the workload of the nursing and the laboratory staff. A committee was set up to address the problem, which included the director of nursing, a consultant microbiologist, the infection control nurse adviser, a consultant surgeon, the domestic services manager and the ward sister. The need for a specific clinical housekeeper role was highlighted by this group as a direct result of the continuing evidence arising from the findings of Rampling et al (2001).
After discussions and consultation with ward staff, the aims and responsibilities of the post were agreed and the post advertised. All concerned felt it was imperative that the person appointed to the role needed skills and abilities that would complement those of the existing ward team. The salary scale was set at nursing grade A, similar to that of ward auxiliaries, as the post-holder would be expected to take on some of their tasks.
The initial job description, as shown in Box 1, reflected the needs identified by the senior ward nurses and the domestic services manager. It was anticipated that this would change as the post developed.
The role in practice
The job description is necessarily prescriptive, in that the post is unique, with the main responsibilities focusing on the prevention of the spread of infection through, among other duties, the cleaning of ward clinical equipment. This is a task that normally falls to nurses, often adding to an already overstretched workload, and one that is consequently neglected when pressure of work demands direct patient care. Good infection control practices are frequently directly attributed to the level of nursing workload; however, outbreaks of MRSA place even greater demands on the nurse (Farrington et al, 1998).
The appointed clinical housekeeper had previous experience in domestic duties, and because of the new role's more clinical focus it was important that it was seen as a clinical role. To achieve this, a uniform was chosen that was unlike that worn by any other service, and an induction programme drawn up in conjunction with senior nurses. This incorporated an educational component to ensure the post-holder gained an understanding of infection control procedures. She received training to demonstrate how the pumps and monitors worked in order to be able to dismantle them for cleaning, and on how to test and clean all oxygen and suction points, including portable oxygen and Entonox.
The clinical housekeeper spent some time with the infection control nurse adviser to gain an overview of isolation procedures and an understanding of practical issues such as obtaining swabs correctly. During the first two weeks in post, the post-holder was asked to record how long each area took to clean. 'Grey' areas were included in this. These are areas for which no one had specific responsibility and were cleaned on an ad hoc basis, usually at the weekend, such as patients' telephones and drug fridges.
A timetable was then drawn up on the basis of these timings. It was felt important that this offered flexibility. For example, if a priority arose such as if a patient in the open ward was found to be infected with MRSA, the post-holder could assist in the patient's move to a cubicle and liaise with domestic staff to ensure swift disinfection of the bed space. She would ensure the disposal of items such as oxygen and suction tubing, and clean items such as sphygmomanometers to prevent the spread of infection.
Further elements of the role included responsibility for reorganising the clinical treatment room, restocking as necessary, and taking responsibility for the safe working and disinfection of manual-handling equipment after each patient use, which Boden (1999) established was an area that posed a risk of cross-infection. Cleaning the environment also included mobile equipment such as intravenous infusion and catheter stands.
Development of the role
The clinical housekeeper was encouraged to use her initiative to be alert to areas that needed attention and to communicate this to the senior nurses. After the first six weeks, the housekeeper and senior nurses discussed and updated the timetable as necessary. One of the findings was that areas such as storage containers were now taking less time to clean, as they were being cleaned more frequently.
This left time free for the clinical housekeeper to develop her computer skills to follow up swab results, and carry out daily monitoring of the use of the isolation cubicle. This has improved the use of the cubicles, ensuring patients are allocated to them appropriately, leading to better liaison and communication between the ward and the hospital bed management team via the senior nurses.
Areas that needed upgrading, such as a cracked tiled floor, or a faulty shower or a leaking bedpan washer, were reported and dealt with more quickly than before. Close liaison between the housekeeper and the maintenance department means that any outstanding requisitions for repairs are followed up within 48 hours. The clinical and clerical environments have been reorganised to achieve greater efficiency. The housekeeper has responsibility for the maintenance of patients' beds, mattresses, lockers, wardrobes and bed tables, and for dealing with equipment or stock queries.
Developments such as these have had the added benefit of keeping the post-holder interested and motivated. However, it has been felt that some caution is necessary to avoid losing the main focus of the role, which is infection control.
Benefits of the post
The ward team and the housekeeper feel the role complements patient care, as opposed to fragmenting it, since the majority of the tasks taken over by the new role, although vital to the smooth running of the ward, were indirectly associated with the patient. This enabled nurses to spend more time with patients, giving them greater job satisfaction and improving nurse-patient relationships. The domestic staff worked closely with the housekeeper, as their role in cleaning the ward environment is crucial to maintaining adequate standards of hygiene (Griffith et al, 2000).
The benefits of the clinical housekeeper role in the fight against nosocomial infections cannot be overstated. The most important benefit has been a lower incidence of MRSA, identified by pre- and post-implementation monitoring by the infection control team. Figures collected every month as part of environmental monitoring - not yet published but communicated verbally to the ward team - indicate that the area has remained free of MRSA. This is directly attributed to, and accepted as, the result of the increased environmental cleaning carried out by the clinical housekeeper.
Consequently, there has been a reduced cost in the drugs bill, a reduction in the cost of equipment, such as aprons, masks and gloves needed to nurse isolated patients, lower laundry costs, less time spent cleaning and disinfecting the cubicles, and less nursing time spent preparing to enter and leave the cubicles.
The work of the clinical housekeeper has also reduced the number of patients who need to go into isolation because of infection. Although some may appreciate a single room others, especially older patients, can become depressed and lonely when segregated (Gammon, 1999).
Further benefits include monitoring the amount of consumables used and those 'borrowed' by other wards, and minimising wastage by ensuring effective stock rotation. The clinical housekeeper acts as a link between nursing staff, who highlight the efficacy of particular dressings, lines or equipment to her. Any alternative items are then brought to the attention of the ward sister and staff, who assess each item for cost and performance, ensuring a cost-effective use of stock. The cost of employing the housekeeper is outweighed by the benefits of eradicating MRSA in patients.
Implications for nursing
One of the major positive implications is that infection control procedures have become a high priority for all staff. There is an increased awareness among nurses of the need to ensure that all staff, whatever their profession, stringently observe universal precautions, and standard infection control guidelines. By maintaining a clean ward environment, patients are protected from infection risk as far as possible.
The monitoring and audit of infection allows patients to be isolated and treatment to be commenced where appropriate, thus safeguarding patients and staff. Anecdotal evidence suggests that nurses feel reassured that the equipment they use is clean, so their time is spent on patient care rather than cleaning. Better use of consumables ensures that the most appropriate dressing, giving set or catheter is accessible, that it is in date and available for the patient who needs it. Communication between the members of the ward team and other departments has greatly improved, promoting a smoother working relationship for all concerned. These issues have contributed to the improvement of nursing care.
Evidence to support the efficacy of the role is provided by the reduced incidence of MRSA in the ward. The prevalence of MRSA in the general community (Benbow, 1998), the organism's ability to mutate, and the admission of infected patients to the ward who have not previously been screened and identified as infected means MRSA is unlikely to be ever totally eradicated.
However, we have found that the role of clinical housekeeper, as described in this paper, in a large surgical ward with a high patient turnover is a successful and cost-effective model. Such has been the success of the role that when Junior Health Minister Hazel Blears visited the hospital she met the housekeeper and expressed great interest in this development.
Every patient has the right to expect to be nursed in a clean environment, and government directives dictate the instigation of ward housekeepers, with cleaning services under the governance of the modern matrons (Hewison, 2001). This model was not developed in answer to these, but rather as a complementary role, with the clinical housekeeper being an integral member of the ward team in the fight against infection. Within this, it is vital that the ward sister remains responsible for the management of the role in order for it to maintain direction and effectiveness in the ward.
Although the Government has directed the instigation of the ward housekeepers, and some of the duties will overlap, there appears to be little evidence that this particular role has been implemented in other hospitals. The role itself is one of co-ordination and communication, and has improved the cleanliness of both the equipment and the environment, and would be an asset to any clinical area.
Further work, however, could include more specific monitoring procedures, such as identifying the sources and causes of other infections that occur in hospitals, and monitoring the incidence of MRSA in the wider population before patients' admission to hospital.
- The authors would like to thank Denise Doe, Clinical Housekeeper, for her help in the implementation of this role
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