Surface Hygiene

An environmental cleaning bundle and healthcare-associated infections in hospitals (REACH): a multicentre, randomised trial

Healthcare-associated infections (HAIs) are causing prolonged stays in hospitals and pose a substantial burden for healthcare services and population. Frequently touched surfaces like bed rails and door handles are contributing to the unintended transmission of pathogens, since many of them can persist on inanimate surfaces for up to several months [1].


The REACH study

Brett Mitchell and his team have conducted a multicentre, stepped-wedge randomised study focussing on environmental cleaning and disinfection, called Researching Effective Approaches to Cleaning in Hospitals (REACH). On the one hand, the bundle of measures aimed to reduce the incidences of HAIs. On the other hand, the thoroughness of cleaning of frequent touch points was ought to be improved [2]. In this study eleven Australian hospitals participated for 20-50 weeks. In this period, 1,729 staff members cleaned in total 190 wards.

The cleaning bundle included the following measures:

  • recommendations on cleaning agents and frequency of cleaning
  • cleaning techniques
  • auditing strategies
  • environmental cleaning staff training
  • creating a hospital-wide commitment to improved cleaning

The primary outcome for evaluation of the intervention were the incidences of HAIs caused by Staphylococcusaureus (methicillin-resistant and -sensitive), Clostridioides difficile, and vancomycin-resistant enterococci (VRE). The second outcome was defined as the thoroughness of cleaning of frequently touched points assessed by a fluorescent marker.


Results of the study

The introduction of the multimodal cleaning bundle caused a significant decrease in VRE-associated infections (see figure), whereas no significant changes were observed for S.aureus bacteraemia and infection with C.difficile. With regard to its survival in hospital environments and the way of transmission, VRE can serve as surrogate for other bacteria (e.g., Acinetobacter) [3], thus, the reduction in infections caused by VRE can be extended to other pathogens.

Positive results were also achieved for the thoroughness of cleaning. Before the intervention, only 55% of the frequent touch surfaces in bathrooms were cleaned, in bedrooms 64%. The cleaning process improved to 76 % and 86%, respectively, by introduction of the bundle.

[Figure: Results of the REACH study. Left: Changes in the incidences before and after introduction of the cleaning bundle. Right: Improvement in the thoroughness of cleaning of frequent touch points due to the intervention.

Conclusion

The REACH study was the first multicentre, stepped-wedge randomised study focussing on environmental cleaning and disinfection. The introduced cleaning bundle improved the thoroughness of the cleaning of frequent touch points and caused a significant reduction of the incidence of vancomycin-resistant enterococci.


References:

1. Kramer A et al. (2006) BMC Infect Dis 6:130.

2. Mitchell BG et al. (2019) Lancet Infect Dis 19(4):410-18.

3. Tacconelli E et al. (2014) Clin Microbiol Infect 20:1-55.

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