[CUPE healthcare list] cleaning critical to controlling infections; contracting-out raises risks and costs (literature review)

["Irene Jansen" <ijansen@cupe.ca>]

Please find attached an excellent literature review that Janice Murphy wrote for the Hospital Employees' Union/CUPE. It examines the relationship between cleaning services and healthcare acquired infections and the particular impact of contracting-out. In reviewing the findings of over eighty studies, the vast majority published in the last five years, the researcher found a large body of evidence that cleaning plays a vital role in healthcare infection control and that contracting-out, understaffing and high turnover of cleaning services contributes to increased infection rates. HEU tabled this research in its Bill 29 meetings last week.  

 

Summary:

 

In 2002, a review of the research literature demonstrated the link between effective cleaning of health care facilities and reduced nosocomial or healthcare associated infections. Environmental contamination (e.g. of viruses and/or bacteria) was associated with major infectious outbreaks and thorough, rigorous cleaning of the environment was shown to be key to terminating outbreaks. The review found that understaffing and contracting out of hospital cleaning services also contributed to increased infection rates. Contracting-out of health care cleaning services breaks up the health care team, results in high turnover and higher levels of absence due to sickness, and impedes the provision of integrated, client-focused services.

 

In this updated review of the research, a large number of very recent studies show even more clearly the risks and dangers of contracting-out cleaning services and the important role cleaning places in healthcare infection control. This review includes over eighty studies, ninety percent of which were published between 2002 and 2007. In summary the review shows that:

 

Healthcare associated infections (HAI) are on the rise in B.C. and across Canada, resulting in higher levels of morbidity, mortality, length of hospital stay, health care costs, and institutionalization. A survey of Canadian hospitals (reported in 2000) estimated the direct costs of hospital-acquired infections in Canada to be approximately $1 billion annually.[i]  At the same time, at least 30 percent of HAI can be prevented by following appropriate infection prevention and control strategies.[ii]

 

The primary focus of infection prevention has been on hand washing.  And while unclean hands are still widely considered the primary route of transmission of infectious pathogens, recent research demonstrates that infectious pathogens are able to survive for long periods of time and that patients and health care workers can and do acquire infections directly from the hospital environment.  As microbiologist Dr. Dancer argues, “Even if everyone does wash their hands properly, the effects of exemplary hand hygiene are eroded if the environment is heavily contaminated.”[iii] This new literature points to the importance of hospital cleanliness as an important infection control measure.

 

There are also many more studies detailing how and which organisms contaminate our health care environments, how these viruses and bacteria are transmitted to patients, and which cleaning methods and techniques stop transmission of infections and infectious outbreaks. This literature speaks to the need for increased flexibility in the provision of cleaning services to ensure that standards are kept current and on-going training and support provided to the housekeeping supervisors and staff by infection control nurses who have access to the most recent research. It raises concerns that with contracting out, Health Authorities are no longer responsible for training and flexibility has declined because the standards put in place at the beginning of a contract may not meet changing infection control requirements. Moreover any changes to those standards will have to be negotiated with the contractor and will lead to an increase in the costs to the Health Authority.

 

In addition, researchers have found that routine and terminal cleaning procedures do not always remove pathogens. What is required instead is enhanced cleaning.[iv] Typically, enhanced cleaning is only targeted at rooms or equipment near patients with infections. But research now shows that pathogens can be found on surfaces in areas far from infected patients. As a result overall cleaning standards must be enhanced and increased screening of the environment is required. Given that Health Authorities must pay contractors an additional fee for enhanced as opposed to routine cleaning; these new standards will result in significant increases in the costs of contracting out housekeeping services.

 

In terms of screening the environment, clinical studies show that “visual inspections”, similar to the ones put in place by the Health Authorities following contracting-out, are poor indicators of cleaning efficacy. [v] Microbiological testing of hospital surfaces found that 100 percent of apparently “clean” surfaces carried an unacceptable load of potentially infectious microorganisms. [vi]  This points to the need for a much more rigorous screening and quality assurance processes than is currently in place. It also raises questions about the efficacy of the current process for monitoring cleaning services in B.C. and the dangers of signing long term contracts when the infection control risks of contracting out cleaning are, at best, uncertain. 

 

Finally, there are now many more studies and audits linking increased healthcare associated infections with problems commonly found with contracted-out cleaning services – higher levels of absence, turnover and vacancies, inadequate training and staffing levels, and poor supervision.^[vii] In the June 2007 internal audit report from VCHA, high staff turnover amongst VCHA contracted-out cleaning staff is cited as a primary reason for poor cleaning performance.[viii] And the 2007 report from the Auditor General of British Columbia noted that the contracting-out of housekeeping at Children's and Women’s “was initially acceptable, but that it began to slip when the housekeeping staff continually changed. Another issue was concern over the possibility of increased infections because of lack of adequate training for new staff and relief staff.” [ix] There are similar findings in audit reports from both the Scotland and England. In Britain, they have introduced in-house Ward Housekeepers to compensate for the cleaning not provided by the contractor and Ward Nurses now supervise the contract cleaners – all at a significant increase in cost to the taxpayer.

 

The evidence points, quite clearly, to a significant increase in health risks and the rising costs of contracting out housekeeping services. This is particularly critical given that our understanding of the relationship between infection control and cleaning is constantly evolving.  With contracting out, health authorities lose control of cleaning staffing levels, recruitment and training. They are unable to ensure an on-going and direct link between cleaning, infection control and nursing. This limits their flexibility and increases the costs of responding to evidence-based requirements that enhanced, rather than routine cleaning, is needed to reduce the risk of infection.

 

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[i] Van Iersel (2007a, p. 11).

[ii] Canadian Committee on Antibiotic Resistance (2007).

[iii] Dancer (2007, p. 9).

[iv] Boyce (2007).

[v] Westech Systems FM Inc. (2006 January).

[vi] Malik et al. (2003)

[vii] Andersen et al. (2002); Archibald et al. (1997); Denton et al. (2004).

[viii] Vancouver Coastal Health Authority (2007).

[ix] Van Iersel  (2007f, p. 33).

Attachment: 2007.11.14 Cleaning and Infection Research Literature Review.doc
Description: 2007.11.14 Cleaning and Infection Research Literature Review.doc