By Brian Clark* The recent publication of Draft National Infection Control Guidelines for public comment by the National health and Medical Research Council (NHMRC) was a golden opportunity for the cleaning industry to provide input into a document that will have a dramatic influence on cleaning in Healthcare for the next five to 10 years. […]
By Brian Clark*
The recent publication of Draft National Infection Control Guidelines for public comment by the National health and Medical Research Council (NHMRC) was a golden opportunity for the cleaning industry to provide input into a document that will have a dramatic influence on cleaning in Healthcare for the next five to 10 years.
Some of the Draft’s recommendations reflect the lack of understanding of cleaning and cleaning trends and have created considerable concern and controversy, particularly within the carpet industry. While there was considerable emphasis on the importance of environmental cleaning and selection of appropriate floorcoverings as infection control measures, neither the cleaning nor the floorcovering industry were represented on the working committee.
One of the earliest proponents of cleaning to control infection was a practicing nurse named Florence Nightingale. Her work and that of Joseph Lister, a pioneer in disinfection and asepsis techniques, are enshrined in the annals of the global infection control movement.
The importance of cleaning in infection control was again emphasised in 1974, with the publication of ‘Hospital Hygiene’ by Isobel Maurer. Maurer’s commonsense approach to cleaning and disinfection redefined disinfection policy and set the baseline for modern infection control practices. One of the current proponents of the importance of cleaning in preventing infection in Healthcare is Stephanie Dancer .
According to Dancer, “The introduction of additional cleaning services is easier than improvements in hand-hygiene compliance” and, most evocatively, “.there is little direct evidence for the effectiveness of cleaning because it has never been afforded scientific status.”
Dancer’s second statement is echoed in these draft guidelines. Academic standards and science tend to disappear, to be replaced by broad, unsubstantiated statements whenever cleaning is mentioned.
Carpet, in particular, cops a beating. Section C6.2.3 of the draft contains this statement: ‘The use of carpet can be controversial as it is perceived to be difficult to clean compared with hard floor coverings.’ Perceived? By whom? There are recommendations on page 165 of the draft as to where carpet should not be considered, but there is no evidence provided to support this statement.
Furthermore, there is no evidence presented in the reference documents or in the draft guidelines, which supports recommendations as to design and selection of soft floor coverings or cleaning of soft floor coverings. In fact, there is not a single study in published literature to compare the impact of floor covering selection on the rate of Hospital Acquired Infection with hard versus soft floor coverings.
The draft guideline explains that hard flooring is ‘costing less, as disinfectant is less expensive than steam cleaning, and steam cleaning may not be readily available.’ Hardly academic, verging on the ridiculous and the terminology is incorrect. The terms ‘Steam Cleaning’ and ‘Shampooing’ are freely interchanged in the document, completely ignoring the accepted industry terminology and the Australian Standard AS/NZS 3733:1995, which classes ‘Shampooing’ and ‘Steam’ cleaning (Hot Water Extraction) as two distinct methods. ‘Shampooing’ is described as a ‘Surface Cleaning method’ , while Hot Water Extraction is defined as a ‘Corrective or Restorative Cleaning Method’. Both methods utilise a separate set of equipment, chemical and methodology.
Incidentally, shampooing methods and bonnet buffing are similar methods and are not recommended on many specialist floorcoverings in healthcare, while bonnet buffing has been associated with an outbreak of aspergillosis in an HSCT unit. 
It should be noted that the reference above to ‘costing less’, or cost saving by cutting cleaning services in an infection control context is not supported by literature that is referenced elsewhere in the document. According to Dancer, in a UK hospital study  in which an MRSA outbreak was arrested by increased cleaning, it was concluded that, in the long term, cost cutting on cleaning services is neither cost-effective nor made sense.
Another statement, again in the context of carpet in hospitals and raising alarming implications for exposure to risk and potential litigation, explains that ‘there may be occupational health and safety issues relating to staff vacuuming when compared to mopping..’. The OH&S risks associated with cleaning are different in every site and need to be individually assessed by Job Safety Analysis and risk management programs, rather than by assumption. Each State and Territory publishes detailed injury statistics for the cleaning industry and they should be consulted before including or publishing statements relating to Workplace Health and Safety and Risk management. It could also be stated that safety concerns should also be included with hard floor as there is a significantly increased risk of slip and fall injuries on hard floor surfaces.
It may seem that the tone of this article is harsh, but it is not meant to be a criticism of the NHMRC committee or the guidelines as a whole. Rather, it is the cleaning industry that is failing in its responsibility to advance the science of cleaning and build a credible public image. It needs to stop hiding in dark basement cubby holes and show itself as a trained, professional and essential industry. Industry organisations need to think about building the future, to promote the need for, and even fund, credible research.
Cleaning is an integral component of infection control, yet it is continually overlooked and rarely consulted, except when it comes to cutting costs. The cost of proper cleaning in healthcare is miniscule compared to the loss of life and quality of life and the ongoing treatment costs of infected patients.
Overall, the industry needs to become expert in the science as well as the mechanics of its trade. Until then, cleaning will remain all too hard or maybe not that important in the eyes of those that control the funding and set policy.
1 Dancer, SJ. ‘Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning’. Lancet Infect Dis 2008; 8: 101-13
2 AS/NZS 3733:1995 Section 2, subsection 2.1.4 Guidelines page 7.
3 44) Gerson SL, Parker P, Jacobs MR, Creger R, Lazarus HM. Aspergillosis due to carpet contamination [letter]. Infect Control Hosp Epidemiol 1994;15:221-3.
4 Rampling A, Wiseman S, Davis L, et al. Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2001; 49: 109-16.