Fiona Baker, BSc (Hons) Life Sciences, RGN.
Clinical Nurse Specialist Infection ControlThe issue of cleaning in hospitals has received much attention in recent months. There has been a great deal of activity from a number of organisations such as the Infection Control Nurses' Association (ICNA), the Association of Domestic Managers (ADM), the National Patient Safety Agency (NPSA) and the Department of Health (DH), to name only a few.
The issue of cleaning in hospitals has received much attention in recent months. There has been a great deal of activity from a number of organisations such as the Infection Control Nurses' Association (ICNA), the Association of Domestic Managers (ADM), the National Patient Safety Agency (NPSA) and the Department of Health (DH), to name only a few.
Public involvement and awareness of issues relating to infection control and cleaning in hospitals has been actively pursued, and there has been much media coverage of the topic.
Undoubtedly, for many the issue of hospital cleanliness and healthcare-acquired infection (HAI) are inextricably linked, despite the evidence available.
Key publications concerned with the issue include the following:
- A Matron's Charter: An action plan for cleaner hospitals (DH, 2004a)
- Towards Cleaner Hospitals and Lower Rates of Infection (DH, 2004b)
- NPSA Clean Your Hands campaign (NPSA, 2004)
- ICNA Audit Tool for Monitoring Infection Control Standards (ICNA, 2004)
- National Standards of Cleanliness for the NHS (NHS Estates, 2001).
A Matron's Charter outlines how patient groups will be involved in helping monitor standards and identifies that cleaning in the NHS is 'everybody's' business.
Detailed cleaning frequencies for hospital equipment and environments are set out in the National Standards of Cleanliness, and the ICNA audit tool has been devised to help assess and monitor these standards, with particular attention to aspects with infection control implications.
In February 2005 many NHS trusts will take part in the 'Think Clean Day' (see box below).
What is cleaning?
In infection control terms cleaning is the physical removal of organisms. In the hospital environment it is seen as the act of removing dust, spillages and visible dirt or soiling. While a minority of hospital environments, including theatres, are concerned with reducing micro-organisms to as low a level as possible, the majority of wards, departments and non-invasive shared equipment cannot be rendered completely free of microbes.
The aim of cleaning is to provide a safe working environment in two main ways. First, by reducing the number of organisms to an acceptable level and, second, by creating an environment in which hygienic practices, and attention to preventing cross-infection, can be promoted and facilitated.
Past and present cleaning practices
Evidence for the use of traditional phenolics and bleaches in reducing incidence of infection is unclear, and therefore these products are no longer widely used in the NHS. Consequently, many hospitals no longer have that 'hospital smell'.
Anecdotal evidence suggests there is now a belief in the NHS that 'nurses nurse and cleaners clean' and that it is no longer appropriate for nurses to spend time cleaning equipment. The old routines of nursing included regular damp dusting and keeping equipment clean, which were as much a part of the nurse's role as patient care.
Equipment cleaning was achieved using a bowl of hot water and detergent, a method which is still appropriate today. However, the availability and convenience of individually packaged wipes means that disposable wipes are now used instead of the traditional bowl of soapy water.
As alcohol was traditionally used to disinfect dressings trolleys, the use of alcohol-impregnated wipes has been seen as preferable for infection control by many nurses. However, it is important to assess the cleaning task and to select the most appropriate product.
'Damp dusting' remains an important part of environmental cleaning. Work is under way to introduce new technologies to cleaning based on this method, such as the microfibre cleaning system, which many trusts are trialling.
Microfibre is a fine, spherical (pie or orange-shaped) fibre with a thickness of less than 1 dtex = 1g/10.000m. It is composed of two polymers: 70% polyester (which absorbs grease and dirt) and 30% polyamide (which absorbs water). Cleaning products made using microfibre are resistant to tearing and snagging and have low levels of linting (shedding fibres). When a microfibre cloth is dampened a capillary action sucks up dirt and moisture at higher levels than conventional cloths and as only minute particles are released there is no need for a second wipe to dry surfaces.
There is a wide range of disposable wipes now available and it is important to select the most appropriate for the task being considered.
The following list outlines the types of wipe available:
- Dry disposable wipes for patient hygiene
- Moist disposable wipes for patient hygiene
- Moist disposable detergent wipes for hard- surface cleaning
- Moist disposable alcohol-impregnated wipes for hard-surface cleaning
- Moist disposable quaternary compound- impregnated wipes for hard-surface cleaning.
The table above provides a guide to some of the patient skin cleansing wipes available.
Dry and moist disposable patient wipes
It has long been recognised that a bed bath, while making a patient more comfortable and 'clean' may actually spread micro-organisms around the body. Good infection control practice dictates using disposable dry wipes and a bowl of water, and changing the water frequently. The advent of moist impregnated wipes may be of benefit because the wipe is discarded after use and not returned to the bowl.
Personal preference and experience will determine whether a dry wipe and soap and water are more effective cleansers than an impregnated/moist wipe. From an infection control viewpoint there is probably little difference.
There is a move towards encouraging and facilitating patient hand hygiene. Individually packaged moist wipes for this purpose are now becoming available. There is little evidence that these wipes have as great an impact on the removal of transient flora as mechanical hand washing with soap and water.
The following factors must be taken into consideration when using moist patient wipes:
- Although dermatologically tested, wipes that are moistened/impregnated with soaps and perfumes may cause some people to suffer skin irritation or allergic reactions
- Not all disposable wipes for patient hygiene can be disposed of in a macerator as they do not degrade sufficiently and can cause breakdown of the machine, which may be both inconvenient and expensive
- Some disposable patient wipes are available in multi-packs. There is a small risk that packs can become contaminated and lead to cross-infection between patients.
Hard-surface wipes fall into two main categories: those impregnated with detergent and those impregnated with chemicals such as alcohol or quaternary compounds.
The first object of cleaning is to remove any organic matter and visible soiling. The application of a chemical to 'disinfect' a surface or piece of equipment will not be effective if any organic matter remains because the chemical will not fully penetrate it. Therefore, when selecting a hard-surface wipe, it is important to establish whether disinfection or cleaning of a surface or object is required.
For some chemicals, surface contact time is significant in order to enable disinfection to occur. It is also important to check that surfaces and equipment to be cleaned are compatible with the chemical in the wipe.
As highlighted with the use of impregnated disposable wipes for patients, the issues of skin irritation/reactions, disposal methods and multi-use packs should be considered.
This article has highlighted the increasing variety of disposable wipes available to nurses for both patient and environmental hygiene.
The availability of these products can help nurses meet the challenge of the new standards of cleanliness and the Matron's Charter.
Think clean day
The aim of Think Clean Day on February 28 is to raise the profile of cleaning and demonstrate what can be achieved in a short time. Participating trusts have been asked to:
- Bring together nursing and facilities managers
- Use the ICNA toolkit on Patient Environment and Patient Equipment
- Audit at least one ward or department
- Solve all possible problems on the day
- Develop an action plan to deal with longer term problems.
Trusts can give their day a local dimension, perhaps by auditing several wards, holding a 'Think Clean Month' or by linking to the 'Clean Your Hands' campaign. It is important to get support from all staff and to celebrate successes.
Author contact details
Fiona Baker, CNS Infection Control, North Devon Healthcare Trust. Tel: 01271-322680
Department of Health. (2004a)A Matron's Charter: An action plan for cleaner hospitals. London: DH.
Department of Health. (2004b)Towards Cleaner Hospitals and Lower Rates of Infection. London: DH.
Infection Control Nurses' Association. (2004)Audit Tools for Monitoring Infection Control Standards. Available at: www.icna.co.uk
National Patient Safety Agency. (2004)Clean Your Hands Campaign. Available at: www.npsa.nhs.uk/cleanyourhands
NHS Estates. (2001)National Standards of Cleanliness for the NHS. London: The Stationery Office.