Clean Hospitals With Alexandra Peters, PhD: The Double-Edged Sword of High-Tech

Clean Hospitals Corner With Alexandra Peters, PhD

True revolutions happen comparatively rarely in infection prevention compared to other fields of medicine.¹ I would argue that the main one in the last 30 years was a shift from cleaning hands with soap and water to using alcohol-based hand rubs at the point of care. On the one hand, this shift was convenient because hand rubbing can be performed anywhere, takes much less time than washing hands correctly, and is ultimately less damaging to the skin.

(A quick aside is that although alcohol does cause dryness, if people wash their hands as often as they should be rubbing them in intensive care units, that would mean 30 minutes out of every hour, and nobody would have any skin left on their hands.)²

The behavioral aspects of this revolution were equally as important as the technical ones. Combined, these aspects created what would become the World Health Organization's 5 Moments for Hand Hygiene.³ These were identified by studying countless hours of patient care activities to identify and categorize crucial moments in the chain of transmission. True revolutions occur comparatively rarely in infection prevention, unlike in other areas of medicine.

The internalization of these 5 moments by health care staff not only enables them to reduce transmission to patients and protect themselves, but it also gives them a deep understanding of the chain of transmission and how it relates to the organization and sequences of care they give their patients.

Although some models akin to the WHO 5 Moments have been proposed for environmental hygiene, the necessary scientific process of observation of cleaning activities in patient areas has not been performed, and so recommendations so far concerning the moments of environmental hygiene have been mainly based on common sense and not on evidence gathered in health care settings. Nevertheless, we all know that many instances of increased transmission in environmental hygiene are linked to the behavior of environmental service (EVS) workers. Some of this behavior might be hand hygiene, but the rest of it also has to do with the organization of the cleaning cart, the sequence of what is cleaned in a room, the products and supplies that are used, and the technique with which these are applied to surfaces.

We know that in some settings, there is still very low adherence to hand hygiene and environmental hygiene both by clinical staff and EVS staff, which puts patients at an increased risk of health care-associated infections (HAIs),⁴ and when counted together, are the leading causes of outbreaks in health care settings. Hand hygiene is estimated to cause over 50% of HAIs,⁴ and the health care environment, although there is less data, shows a more than 2-fold higher chance of transmission of pathogens from colonized and infected prior room occupants⁵ and that the environment is responsible for an estimated 10 to 30% of multidrug-resistant organism transmission after terminal cleaning,⁶ which means that the full range of transmission is likely much higher.

The Technology

Over the last 10 years, the market has been inundated with products touting themselves as solutions to HAIs. Although a good percentage of them do not have a scientific basis, a number holds a lot of promise. Automated disinfection has come a long way from 10 years ago, with some good studies available now on gaseous hydrogen peroxide disinfection (HPV and aHP) and UV-C disinfection specifically. These technologies are no longer new and have shown clear value in some clinical settings. More recently, in the last 5 years, we've started to get an important body of literature concerning different types of antimicrobial surfaces, although there is still a need for good clinical studies. Probiotic cleaning is another field with much promise and will hopefully advance rapidly in the next few years. Other technologies, such as hypochlorous acid-based hand rubs and products for hand hygiene with remnant antimicrobial effects on the skin, also look quite promising.

Yet, what I run into over and over again is that some of the manufacturers of these products and machines and some of the health care facilities that implement them try to portray these technologies as replacements for human knowledge and a high-quality workforce. One of the basic tenets of environmental hygiene is that you cannot disinfect a dirty surface.

Currently, most surfaces in health care facilities are still cleaned by hand. Although we know that due to a lot of human factors (including lack of training and monitoring, little management, low wages, time pressure, etc), quality is often low, we are not (yet?) in a place we are investing in technology instead of people will improve patient outcomes. Even if antimicrobial surfaces can flatten the spikes of surface recolonization over time, and hand hygiene products with remnant effects can make patient care safer when health care workers inevitably forget to perform hand hygiene at the right moment, they are not and should never be, seen as a first line of defense.

If a health care facility is trying to reduce the frequency of cleaning (which is usually only 1 time per day in most settings anyway) and the costs of EVS staff by installing antimicrobial surfaces or try to reduce the need for training by telling staff to apply a product with a remnant effect less often, they are eroding their staffs’ understanding of the chain of transmission. In the long run, doing so will increase the number and severity of mistakes throughout the whole organization and working process. These technologies all hold a lot of promise and can make it easier for facilities to reach a level of excellence, and they should be treated as such.

If we forget that it's people who provide health care, we will be opening a Pandora’s box with negative effects that will extend far beyond using an incorrect technique to wipe a surface or missing an opportunity for hand hygiene.

References

1. Vermeil T, Peters A, Kilpatrick C, Pires D, Allegranzi B, Pittet D. Hand hygiene in hospitals: anatomy of a revolution. J Hosp Infect. 2018;100(3):243-255.
2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356(9238):1307-1312.
3. World Health Organization. Your 5 moments for hand hygiene. Accessed [date]. https://www.who.int/multi-media/details/your-5-moments-for-hand-hygiene-poster
4. World Health Organization. Key facts and figures: World Hand Hygiene Day 2021. Published 2021. Accessed [date]. https://www.who.int/campaigns/world-hand-hygiene-day/2021/key-facts-and-figures
5. Mitchell BG, Shaban RZ, MacBeth D, Russo PL, Cheng AC. Risk of organism acquisition from prior room occupants: An updated systematic review. Infect Dis Health. 2023;28(4):290-297.
6. Chen LF, Knelson LP, Gergen MF, et al. A prospective study of transmission of multidrug-resistant organisms (MDROs) between environmental sites and hospitalized patients—the TransFER study. Infect Control Hosp Epidemiol. 2019;40(1):47-52.