Annette Jeanes, MSc, RGN, SCM, DipN, Dip IC.
Lead Nurse, Infection Control, University Hospital Lewisham, London
Nurses have a responsibility to ensure an optimal health-care environment, to enable patient recovery, respite or relief. The level of noise, the temperature and the amount of light are all important, but the cleanliness of the environment is crucial, conferring a sense of safety and comfort and promoting an atmosphere of competent caring.
Despite generally held views that environmental cleanliness is vital for infection prevention, there is little current robust evidence to support this view (Dancer, 1999). Although a major focus of attention in the past, in the late 20th century the environment was largely dismissed as insignificant in the transmission of infection in hospitals (Maki et al, 1982; Collins, 1988). However the decline in the standards of hospital cleaning in the UK coincided with the rise of antibiotic-resistant micro-organisms and a ready cause and solution was sought. The role of the environment as a potential source of micro-organisms once again became important. The current perspective of the general public is that cleanliness denotes a well-ordered and safe health-care environment. The media, the Government and pressure groups such as the Patients’ Association reinforce this view.
The NHS Plan (DH, 2000) offers a structure and strategy to improve hygiene in health care. One aim was to reduce health-care-associated infection. The plan revived the role of matrons and renewed the expectation of clean hospitals. Matrons were to have the power and authority to improve the patient environment. The ethos was one of ownership and of valuing team members such as cleaners and housekeepers. The views of patients and users were to be valued. The need for regular maintenance and sufficient resources was also identified. These themes have continued throughout more recent documents, including A Matron’s Charter (DH, 2004a).
Improvements in health-care cleaning
Patient Environment Action Team inspections (PEAT) were established to measure standards achieved in several areas, including cleaning and involved patient assessors. This has had a positive effect in many trusts. NHS Estates has also produced several documents, including Standards for Environmental Cleanliness in Hospitals (NHS Estates and ADM, 2000), the NHS Healthcare Cleaning Manual (DH, 2004b) and the Healthcare Facilities Cleaning Manual (NHS Estates, 2004), all of which are available online. Several other documents from Scotland and Wales have focused on environmental hygiene and basic infection control and in 2003 Winning Ways (DH) specified this as an action area for reducing health-care-associated infection in England.
The infection control perspective is that, while dust and stains may be unsightly, they often pose no infection risk to patients. An example is a dried bloodstain on a theatre ceiling. While this may look bad, it is only a risk if it comes into contact with a vulnerable person. In contrast multiple use items that may look clean, for example pulse oximeters or manual-handling equipment, may be covered in pathogenic organisms (Wilkins, 1993; Barnett et al, 1999). To prevent infection occurring it is important to recognise the potential for the environment or equipment to cause infection to the individual. Contact, for example touching, or an effective method of dispersal such as aerosolisation, is required for transmission to occur. An untouched, rarely disturbed surface is not therefore a major hazard.
Risks from environmental surfaces
Probably the most important risk is the environmental interaction with the health-care worker, visitor and patient. Hand hygiene of health-care workers is important but the surfaces and areas with which people are in contact have the potential to act as a reservoir of micro-organisms - examples include keyboards, curtains and catheter bags.
More than 30 years ago studies showed that there is a limit to how clean facilities particularly the floors, can be kept while they are in constant use (Ayliffe et al, 1967). Despite this evidence, the focus of many health-care environments in the UK is the cleaning of floors rather than surfaces and equipment that is in contact with patients. If staff have clean hands and touch clean surfaces, the risk of transmission of micro-organisms will be low. If staff touch dirty surfaces and then a patient, there is a risk of transmission.
The patient’s perspective
While some nurses and midwives may argue about what cleaning they should do, ensuring the environment is clean is within their sphere of responsibility. If the state of the environment is unsatisfactory, patients expect that staff will be able to do something about it. Sometimes it is helpful to view the environment from the patient’s or visitor’s perspective (see Box 1) as staff working in an area over a long period may be oblivious to the problems.
The role of the nurse in cleaning
Part of the role of the nurse is to facilitate cleaning, to determine cleaning requirements, to monitor the quality of cleaning and, where necessary, to supplement cleaning, for example by dealing with body substance spillages or cleaning a washbowl after use.
Some routine cleaning is part of the work of a nurse, for example cleaning a dressing trolley before use or cleaning the commode between patients. Sometimes nurses will have to do other general cleaning in an emergency but should recognise that health-care cleaning is a skill and requires knowledge and training.
Cleaning skills and methods
Expectations that cleaners will be able to do everything are unrealistic, so it is important that all health-care staff participate in keeping the environment clean and tidy. While routine general cleaning should be undertaken by trained cleaning staff, nurses and other health-care workers should familiarise themselves with the whereabouts of equipment should they need to use it. It is also important that staff are trained how to clean and how to use cleaning equipment. A recent online publication by NHS Estates gives very helpful information about cleaning methods and equipment (available at: http://patientexperience.nhsestates.gov.uk/clean_hospitals/ch_content/cleaning_manual/ infection_control.asp).
This also includes the national colour-coding system of the British Institute of Cleaning Science (see Figure 1). This colour codes areas to be cleaned to prevent cross contamination. The colour-coding system also relates to all cleaning equipment, cloths and gloves.
Cleaning equipment for nurses
It is important that nurses adopt and have access to the same systems as the trust cleaners. It is not acceptable to have a mop and bucket ‘for the nurses’ which is left festering in a dirty utility room. Such items are frequently a potential source of contamination.
In addition to standard cleaning equipment, disposable wipes are a useful resource. Disposable detergent wipes remove debris and are useful for commodes, bedpan holders and drip stands. Alcohol-based wipes are useful as secondary cleaning after debris has been removed such as on dressing trolleys.
Other sprays and substances may also be appropriate, particularly when used with disposable cloths. Made-up solutions will have a limited life, so use them and then dispose of them. They should be kept in originally labelled containers that include the batch number and expiry dates. Disinfectants should be used in accordance with the institution policy.
Protective equipment and safety
Standard disposable gloves are not designed for prolonged cleaning tasks and may deteriorate rapidly, offering little protection. Use household-grade gloves for cleaning tasks where possible and wash hands on the removal of gloves.
Wearing a disposable plastic apron during cleaning prevents contamination of clothes. Splashing or aerosolisation may occur. Select appropriate equipment to protect the eyes, nose and mouth if such a risk is identified.
Always ensure that electrical equipment is both switched off and unplugged or that it is safe to wipe over while plugged in.
Frequency of cleaning
Until recently there was little guidance on how frequently the environment and equipment should be cleaned. The Revised Guidance on Contracting for Cleaning (NHS Estates and DH, 2004), details cleaning frequencies of common items and includes comprehensive advice on quality monitoring. The document focuses on hospitals and determines cleaning frequencies according to the risk of them not being adequately cleaned. Very high-risk areas include operating theatres, accident and emergency departments and intensive therapy units. High-risk areas include general wards, sterile supplies stores and public toilets. Significant risk areas include laboratories, outpatient departments and mortuaries. Low-risk areas include administrative and record storage areas. Each area is divided into elements that include the floor, fixtures and equipment. Each element is allocated a frequency. Some examples of the guidance are set out in Table 1 and may form the basis for dialogue about cleaning schedules.
It is difficult for cleaning staff to clean a poorly maintained environment and they may not have the authority or ability to request repairs. Staff should regularly check their areas for faults and repairs that are required and ensure that these are followed up and resolved. The general decor, flooring and furniture should be reviewed critically and regularly.
The public perception is that nurses have a responsibility for the cleanliness of health-care facilities. Nurses do have a role in ensuring cleaning is done and is of a good standard. However, cleaning is a time-consuming skill that requires training, equipment and resources. One of the hardest problems is to determine who cleans what, when and how, particularly when equipment is involved. The recent guidance from NHS Estates offers comprehensive information on what is required. Nurses should be aware of this and understand how they can contribute positively to a clean health-care environment.
A Matron’s Charter (DH, 2004a) sets out the following commitments:
- Keeping the NHS clean is everybody’s responsibility
- The patient environment will be well-maintained, clean and safe
- Matrons will establish a cleanliness culture across their units
- Cleaning staff will be recognised for the important work they do. Matrons will make sure they feel part of the ward team
- Specific roles and responsibilities for cleaning will be clear
- Cleaning routines will be clear, agreed and well-publicised
- Patients will have a part to play in monitoring and reporting on standards of cleanliness
- All staff working in heath care will receive education in infection control
- Nurses and infection control teams will be involved in drawing up cleaning contracts, and matrons have authority and power to withhold payment
- Sufficient resources will be dedicated to keeping hospitals clean.
Author’s contact details
Annette Jeanes, Lead Nurse, Infection Control, University Hospital Lewisham Email: firstname.lastname@example.org
Ayliffe, G.A.J., Collins, B.J., Lowbury, E.J. et al. (1967)Ward floors and other surfaces as reservoirs of hospital infection. Journal of Hygiene (Cambs) 365, 515-536.
Barnett, J., Thomlinson, D. Perry, C. et al. (1999)An audit of the use of manual handling equipment and their microbiological flora: implications for infection control. Journal of Hospital Infection 43: 309-313.
Collins, B.J. (1988)The hospital environment: how clean should a hospital be? Journal of Hospital Infection 11: (suppl A), 53-56.
Dancer, S.J. (1999)Mopping up hospital infection. Journal of Hospital Infection 43: 85-100.
Department of Health. (2000)The NHS Plan. London: The Stationery Office.
Department of Health. (2003)Winning Ways: Working together to reduce healthcare associated infection in England. London: DH.
Department of Health. (2004a)A Matron’s Charter: An action plan for cleaner hospitals. London: DH.
Department of Health. (2004b)The NHS Healthcare Cleaning Manual. London: DH.
Maki, D.G., Alvarado, C.J., Hassemer, C.A. et al. (1982)Relation of the inanimate environment to endemic nosocomial infections. New England Journal of Medicine 307: 1562.
NHS Estates and the Association of Domestic Management. (2000)Standards for Environmental Cleanliness in Hospitals. London: Stationery Office.
NHS Estates (2004)The Healthcare Facilities Cleaning Manual. London: DH.
NHS Estates and DH. (2004)Revised Guidance on Contract Cleaning. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4097532&chk=REP8s6
Wilkins, M.C. (1993)Residual bacterial contamination on reusable pulse oximetry sensors. Respiratory Care 38: 11, 1155-1160.