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Last Updated: Wednesday, 13 July, 2005, 17:59 GMT 18:59 UK
The importance of keeping clean

Stephanie Dancer
Dr Stephanie Dancer is a consultant microbiologist, who has had many years of clinical experience, dealing with infection control. Until recently she worked for Health Protection Scotland in their Centre for Infection and Environmental Health.

Here she answers commonly asked questions about hospital hygiene and infection, the importance of cleaning and what can be done to fight them.

What are the big hospital infections?

Well it depends whether you're talking about hospital acquired infections or patients coming in with infections. Patients coming in with infections we usually call them community acquired. Infections people get whilst they're in hospitals is usually 48 hours after they come in before the infection becomes apparent. Those are known as hospital acquired infections, and there are a lot. I think if you look at the numbers of people in hospital who get infections, probably the most prevalent would be viral gastro enteritis. MRSA is one, Clostridium Difficile, something called Vancomycin resistant Enterococcus which we call VRE, that's a hospital acquired infection. In fact organisms which tend to be very resistant to antibiotics are the sort of things that you might to get in hospitals simply because of the concentration of patients and the amount of antibiotics being used in a small confined space.

How are most of these infections transmitted and caught?

Infections are transmitted in hospital in a variety of different ways, but I think we're all agreed that the commonest way they're transmitted is by hands, and it's by hands of staff, it's by hands of the patients themselves, it can even be by hands of the relatives, but it's fingertips that have touched a contaminated surface which then transmit the organisms into the patient.

What kind of damage can these hospital acquired infections do?

Well one in ten patients acquire a hospital infection and for most of them it's an inconvenience. For a small number and it tends to be the most vulnerable - these acquired infections can be more serious.

We have an ageing population and so there are a lot of older patients coming into hospital, and as you get older your immunity, your resistance to infection deteriorates with age. So on balance it's the older people who are more likely to get these infections, and unfortunately they all tend to be more compromised by those

I think everybody is concerned about hospital acquired infections. I think patients are; ordinary people in the community who are frightened to come into hospital because they might catch something, one of these so-called super bugs. But I have to say that it's impacted very much on staff, all tiers of staff, porters and ancillary workers, cleaners, kitchen staff, as well as the medical and nursing staff too, everybody is concerned about infections and everybody is concerned about the rate of resistance shown by some of these organisms.

How do you treat them?

It depends what sort of organism it is. If it's a bacterial organism you're looking for an antibiotic. Now we have got lots and lots of antibiotics and I have to say that even for very resistant organisms such as an organism called Acinetobacter and of course MRSA we still actually have one or two antibiotics that we can use and we can use antibiotics in combination as well, so that an antibiotic on its own might not do very much but if we put two together, sometimes even three together, then we can actually get the desired effect and the patient will respond to that. However, I think that history tells us that bacteria are becoming more resistant to antibiotics and I think what we're worried about is that we will lose that, so that in 5, 10, 50 years - who knows? We will be left with very few antibiotics and we won't have that facility to treat these infections.

How important do you think cleaning is in preventing infection?

There are all sorts of different strategies to fight hospital acquired infection, and I would say broadly there are three. Number one is hand washing, number two is antibiotic prescribing and antibiotic consumption and number three is ordinary cleaning.

Now if we go back to hand washing, numerous people have tried with hand hygiene educational programmes, with the alcohol gel that has been funded and is available in every hospital to get staff to wash their hands, and it doesn't work.

You will never get everyone to wash their hands. There are all sorts of reasons for that. So let's take number two. Antibiotic prescribing and antibiotic consumption. We cannot stop prescribing antibiotics. It's unethical. If there's a patient in front of you with the obvious signs of infection, you cannot withhold antibiotics. So we're left with cleaning, and cleaning could be the last remaining defence we have against infection, the removal of dirt.

How important is it for all of us that hospitals are kept clean?

The problem with looking at the relationship between dirty hospitals and patients getting the organisms associated, we think, with dirty hospitals is that there is no evidence. Why haven't we got the evidence? Well it's obvious. Who's going to fund a study on cleaning? Cleaning has always been taken for granted. Cleaning should be an evidence based science, and if we did do that, and if we did fund some studies to look at it, then we could say yes, there is an association between dirty hospitals and the risk of getting a hospital germ. But at the moment we don't have that evidence.

There is no evidence to link visually dirty hospitals with hospital pathogens such as MRSA and Norovirus etc., but in actual fact if you look at studies that have been done over the last half century, and in particular studies that have been done over the last few years at looking at not necessarily MRSA but other organisms too, you can sift out bits and pieces of various studies that show that good environmental hygiene does have an impact on the control of organisms, particularly in the outbreak situation. What we haven't got, of course, is evidence to show us that in the endemic situation where you've got a constant level of a hospital acquired infection, whether increasing the cleaning would actually reduce that rate. Now I think it could, given your hospital pathogen and given the type of cleaning you do, but we haven't got any evidence to back us up on that one yet.

Are you saying that cleaning is really important but there might not be a link?

I think that a lot of people feel there is a link. Now the public put two and two together - super-bugs, dirty hospitals - and they have said that these two are linked, and they have made it quite clear what they think, and the government have taken notice of that. The scientists - and that includes the microbiologists - have been saying we don't know.

I think there's a link. I think there's definitely a link between grime in hospital and the risk of getting a hospital acquired infection, but it's something that we really do need to sort out once and for all because aesthetic appearances are not going to stop patients getting infections.

And the point about cleaning is that whilst hand washing and antibiotic prescribing are very difficult to sort out, it's not difficult to clean.

Cleaning is achievable. I don't see why we can't increase the cleaning hours. I don't think the cleaners have enough time in the hospitals to do the job properly and I think the average cleaner knows what to do and would do a good job if they were just given a little bit more time to do it in.

When you talked about the three different things that are important in infection control and the first one mentioned was hand hygiene. How important is it, why it's important and what do you actually mean by it in terms of how much people need to wash their hands in order for it to be effective?
Hand hygiene is very important, whether it's hand washing or whether it's hand decontamination with some of these alcohol gels that we're using now. We think that the most frequent way that patients acquire their infection is from the hands, whether it's the hands of the patient themselves or the staff or even relatives.

Before and after you touch a patient or you touch something to do with the patient, whether it's the bedside locker or whether it's the drip, or whether it's even just adjusting the patient's pillows, you should actually wash your hands before you go and do that and wash your hands when you finished. Now of course in reality you can't do that. When the nurses are really busy in intensive care, they do not have time to wash their hands. If everybody washed their hands and washed their hands appropriately we'd see the impact on hospital acquired infection but it is not going to happen.

One of the other things that I saw in the hospital was different coloured cloths used for different types of cleaning in different areas. How important is that?

I think it's a step in the right direction that the cleaners have decided to use different coloured cloths, buckets and mops for different areas in the hospital. I think that's a good idea. I think that if you've been using a red mop and red cloths to clean a toilet then as far as I'm concerned then it makes sense to discard those and use a yellow mop and a yellow cloth to clean the hard surfaces next to a patient. To take one cloth from cleaning a toilet to a sink or a bedside table is really not good practice because yes you will be transmitting bacteria that were on an ostensibly dirtier site, to a site which is supposed to be cleaner and which could be touched by staff before they then touch a patient.

Colour coding is an indicator of good hygienic practice, we don't have the evidence for that, it's just common sense. The sort of common sense that Florence Nightingale utilized 150 years ago and I don't think there was anything wrong with what she did. She cut huge rates of hospital acquired infection with soldiers dying from wounds in the Crimean war, simply by cleaning. She didn't have disinfectant, she didn't have antibiotics, all she had was a brigade of nurses who cleaned with soap and water.

As with everything to do with hygiene we have very, very little evidence because you're looking for a microscopic culprit here. You're looking for an organism that you can't see. How do we know that we're actually stopping the organisms getting to patients with using a red cloth for a toilet and a yellow cloth for a sink or whatever. We don't know that. It's just commonsense. That's all we've got to go on. But I think a lot of us feel that it's the right thing to do because at some stage commonsense will turn into scientific evidence. You'll just have to wait for it.

How important are cleaners?

I think cleaners are extremely important. Cleaners are not only part of the health care team, they're actually an integral part of the infection control team, that's why cleaning representatives come to our infection control meetings and they're very good at coming and I don't know how we could manage without them coming and telling us what's going on and whether they need our support in various areas. It's absolutely impossible to run a hospital without cleaners. I think a little bit more attention to cleaning, a few more cleaning hours for cleaners, more attention to training for cleaners and upgrading of the status of cleaners, I think we could see an impact in individual hospitals on rates of hospital acquired infection.

What should people be aware of when treating vulnerable or infected patients in separate barrier rooms?

If you've got patients in side rooms and they are there because they've got an infection with might be transmitted to other patients, every time anybody, whether it's a consultant or a junior doctor or a nurse or a cleaner, goes into that room, even if they don't touch anything, they are at risk of picking up the organism from the patient and they furthermore are at risk of taking that organism to other patients. So it stands to reason, that if you go into an isolation room without gloves, without an apron, without changing water in the bucket, without discarding the mop head in the room before you come out, then you could be taking that infection to other patients.

We know from previous work that if a member of the health care staff goes into a side room with gloves and aprons, if they physically touch the patient, then 2/3 of them with have the MRSA on their hands and on their apron, even on the rest of their uniform, because the apron doesn't cover the whole uniform. We also know that if a member of the health care staff goes into a side room with a patient with MRSA and they come out, then they still could have MRSA on their hands and on their uniform, even though they haven't physically touched the patient. (Reference JM Boyce et al, 1986)

There's also a role for relatives here, when they come into visit their loved ones in hospital, they should not come in if they've got a cold, they shouldn't come in if they've got food poisoning, diarrhoea and vomiting. They can also come in with organisms on their clothes and on their hands and it may well be that they actually transmit organisms that are going to infect the patients in the hospital.

Is it true to say that if it looks clean, it is clean?

No. If it looks clean, great, all the aesthetic principles, box ticked, great. Doesn't mean to say though that it's microbiologically clean. We've all known wards which are cluttered and grubby, and the patients don't get hospital acquired infections. And we've all known wards which looked so clean and shiny that they positively gleam, and yet every other patient that comes in picks up a hospital acquired infection. Now why is that? Yes, okay, we use dirt and grim as a visual indicator of the presence of germs, we don't know whether that really is the truth or not, but on the other hand we have to be aware of even a clean shiny surface can harbour organisms that could actually be transmitted to patients.

Is it important to keep inspecting our hospitals?

I think we should certainly have the visual inspection, that's very important for patient confidence and for staff moral, the place should look clean. However in the future I'd also like to see a scientific assessment of how clean a hospital is, just walking round looking is not really the right way to go about it in the 21st century.

The best way of assessing how clean a hospital is, at the moment, at this point in time, 2005, is to go and look and to smell, because I think smelling the atmosphere is very helpful. But what we must do as well is look for the evidence of pathogenic micro organisms. Now you can use swabs, but that's not quantitative, and the other problem of course with a swab is, a swab is very small and you've got a huge ward, where are you going to put your swab to pick up the organism that you are worried about? So there's got to be a structured surveillance programme using microbiological techniques.

Is it true that there are 5,000 cases of MRSA a year at the moment?

I'm afraid I have no idea how many cases of MRSA there are across the UK. All I can say is that we are measuring the number of positive bacteremias, that's the number of patients who have MRSA in the blood. It's only the tip of the ice berg, it's the most serious infections or a marker for the most serious infections and what we are doing is comparing the rates of these MRSA bacteremias with other countries in Europe and of course we are in the top three. We are in the top three worst of the countries in Europe, for MRSA bacteremia.

The government's hoping by 2008, to reduce the MRSA rate by half, now do you think that's realistic and possible?

I think it's totally unrealistic that the government can expect the hospitals to reduce their MRSA bacteremia rate by half within the next three years. I think it shows a disregard for science to be quite honest, because this is Darwinian evolution, the organism's becoming more and more resistant, we cannot stop what's already happened. It's like King Canute and turning back the tide, you can't turn back the tide of bacterial evolution, this has happened, these organisms are here to stay. I think the best we can hope for is to keep the rate static with maybe even a gradual decline in one or two places in the UK.

So what will happen in the future?

Well we are already seeing ordinary healthy people in the community contracting resistant organisms and becoming seriously unwell from that and even dying and we've seen it happening in other countries, there are other countries where it's actually far worse in the community than it is here in the UK, so it's already happening. We need to be aware of that, we need to reduce our amount of antibiotic prescribing, we need to up the importance of hygiene throughout the whole of society, not just the hospitals.

How important is cleaning?

Cleaning is, I think, a very under valued initiative against hospital acquired infection. I think cleaning is something that we can do. It's not just that it could be effective against hospital acquired infections; it's something that we can do with very little resource. There is no reason why we can't double the cleaning hours in every single hospital in the UK. Also I think there's a grey area. The cleaners are cleaning the floors and toilets and the sinks and the nurses are cleaning the medical and nursing equipment for patients.

The closer a site is to a patient, the more risk there is that if an organism is allowed to stay, then it will infect a patient. Quite often the nurses are so busy that they don't clean properly and they don't clean the clinical equipment properly and it may well be that you've got cleaners who are sorting out the floors and toilets, and that's great, and the ward looks great but in actual fact, the germs we are worried about are on these near patient, hand touch sites close to the patient. These are falling through the hole in the middle, because the nurses are too busy and the cleaners are not given the responsibility to clean those sites.

What's the big fear in terms of infection if the scientists don't manage to find a new strategy to replace antibiotics?

The big worry is untreatable infection. I mean for us as microbiologists and for us as doctors, to not be able to treat a patient because there isn't something available is something that you can't accept as a doctor. So, I think we have to conserve our antibiotics, we have to support research and we have to do our utmost best to find a strategy for conserving our antibiotics and for finding new strategies for the future when the antibiotics run out.

What would you be aware of if you had to go into hospital as a patient?

I'm sure that there are people who are frightened and perhaps would even think about putting off an operation because they don't want to catch one of these nasty germs. I would say to them that the rate is still relatively low and that they should take a big breath, they should come in and get their operation, they should bring clean clothes with them, clean night clothes, bring some alcohol wipes if they want to. Don't be frightened of asking the staff if they've washed their hands, making sure that the visitors wash their hands, but above all, be positive, go for it, because it's still only a very, very small numbers of patients that are getting the really nasty super bugs.



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