Dusting off hospital cleaning measures would help keep patients safer from superbugs, doctors say

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Cleaning contaminated surfaces in hospitals is critically importantto protect patients from drug-resistant superbugs, which are on the rise. But some infectious diseases experts say recent moves to outsource hospital services could compromise the standards of cleanliness and result in poorer infection controls.

In hospitals, cleaning can range from a quick wipe of a door handle to disinfecting sinks to kill microbes or the complete stripping of rooms between patients during an outbreak. Sterilization of surgical instruments happens separately.

One of the latest facilities to consider transitioning to private cleaning is Etobicoke General Hospital in Toronto's west end. The Canadian Union of Public Employees (CUPE) representing cleaning and supportstaff at the hospital held a rally there last week to protest the possible contracting out of cleaning and laundry services.

The union says if cleaning staff suffer cutbacks as proposed by William Osler Health System, the network Etobicoke General belongs to, the level of cleanliness could suffer.

Meanwhile, though it's difficult to show a causal link between outsourcing cleaning and an increase in infections, superbug rates in Canadian hospitals have been climbing. Butthat hasn't deterred facilities from outsourcingcleaning services.Experts say more rigorous attention to cleaning protocols could keep some outbreaks under control.

Dr. Dick Zoutman, a retired infectious diseases physician in Kingston, Ont., says privatizing cleaning services in hospitals isn't as effective as in-house cleaning operated by the hospital and could resultin fewer staff doing the work with not enough resources.

"That just doesn't work in this setting, and it is hazardous to the quality of the cleaning and hazardous to patient care."

In addition to Etobicoke General, William Osler Health System also includes two other hospitals in the Greater Toronto Area that contracted out their cleaning services when they opened in 2017 and 2007, respectively.

Though the hospital network has issued a request for proposals to contract out cleaning at Etobicoke General, no decision has been made, buta spokesperson for Osler said via email that using the same contractor across all its sites was an opportunity to "improve and standardize services and processes." The network noted itiscommitted to "minimizing any impact to patients and staff."

Hospitals in British Columbia, Alberta and New Brunswick have also outsourced housekeeping, according to CUPE. In 2021, B.C. brought cleaning back in-house.

While Canadian data on infection rates is sparse, it does show that the rate of superbugs in hospitals is rising.

The Canadian Nosocomial Surveillance Program pools data from 88 hospitals across the country to give a sense of the types of infections that patients acquired while in hospital.

The 2017-2021 report revealed increases in most indicators, such as MRSA and vancomycin-resistant Enterococcus (VRE).

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Detailed cleaning during outbreaks

CUPE member John Jackson has scrubbed floors, toilets and monitors touched by staff and patients in emergency rooms, operating suites and bedrooms for more than 30 years.

He says hospital cleaning policies have become more stringent over the years to prevent the spread of superbugs strains of bacteria that are resistant to antibiotics, making infections difficult or even impossible to treat.To him,this means it's crucial that sufficient staff are well trained, well paid andgiven the opportunity to clean as often and as thoroughly as needed.

Jackson, who works at Perth and Smiths Falls District Hospital in eastern Ontario, says when he started, outbreaks requiring extra cleaning in the emergency department happened less often.

These days, when a patient is discharged during an outbreak and a room needs to be cleaned, he says, more cleaning staff are brought in because the work has become more detailed and "has gotten harder over time."

Even curtains get taken down and washed, he said, noting that preparing a room normally takes about 15 minutes, but during an outbreak, it can take up to an hour.

Housekeeping for safety

Dr. Michael Gardam, an infectious diseases specialist at Women's College Hospital in Toronto, says when a hospitalized patient picks up a drug-resistant superbug, it raises the question of how they got itand can sometimes mean tracing outbreaks back to a source to determine how to prevent them in the future.

When speed is pitted against infection control, he says, "the two often don't get along very well." He worries that if housekeeping staff feel rushed, things will be missed.

In the hierarchical culture of hospitals, surgeons are at the top, Gardam says, and though housekeeping staff are often seen as an afterthought, he says they're an important part of the team needed to perform surgery safely.

"Our health system is held together with strips of duct tape," he said in calling for a reckoning to make Canadian health care sustainable and safe.

"Part of that is the housekeeping piece."

Gardam says it makes sense that it's possible to control the spread of infections in hospitals by ensuring there are fewer microbes in the environment, yet he says it's a challenge to find "ironclad research" about the return on investment of housekeeping.

In 2017, British researchers published a study examining rates of methicillin-resistant Staphylococcus aureus (MRSA) in 126 English hospital trusts operating health-care facilities from 2010 to 2014.

Though outsourcing cleaning was found to lower costs, the study suggested it was also associated with higher incidences of MRSA, fewer cleaning staff per hospital bed and worse perceptions of cleanliness among staff and patients.

Why cleaning matters

Matthew Muller, medical director of infection prevention and control at Unity Health Toronto, said rates of several drug-resistant bacteria that can thrive in hospitalsare on the rise. "I think all of them are moving in the wrong direction."

The infectious diseases specialist at St. Michael's Hospital in Toronto says infection control focuses on the most harmful pathogens and those resistant to a number of antibiotics.

"All of the basics of cleaning are probably 90 per cent of the battle," Muller said. "One of the reasons that's so important is also because often these cases may initially not be recognized," which can allow some bacteria to gain a foothold.

Clostridioides difficile or C. difficile are gastrointestinal bacteria that cause patients to have severe diarrhea. In more severe cases, Muller says, parts of the colon may have to be surgically removed. Some people don't survive such an infection.

A 2018 study published in the Canadian Medical Association Journal showed that between 2009 and 2015, hospital-associated C. difficile infections across Canada dropped by 36 per cent.

In addition to a decline in a virulent strain of C. difficile noted by researchers, more frequent, intense cleaning of hospital facilities was identified as one of the factorsthat may have contributed to the drop in infection rates.

Spotting invisible pathogens

Stephanie Dancer, a consultant microbiologist in National Health Service Lanarkshire and professor of microbiology at Edinburgh Napier University in Scotland, studies hospital cleaning and hospital-acquired infections.

She says the importance of hospital cleaning has long gone unrecognized. One possible reason for that is that pathogens are invisible to the human eye until they manifest in patients or staff as an infection so the urgency to tackle them is not always apparent until it's too late.

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There are things hospitals can do to assess the effectiveness of their cleaning methods, Dancer said. For instance, during an outbreak, microbiological sampling can reveal how good the cleaning is.

Samples taken from surfaces could be tested to indicate how long it's been since a surface has been cleaned and how effective the process was atremoving germs, as well as the variety of microbes in the environment.

Muller said to test the effectiveness of cleaning at his hospital, they use UV pens to mark different surfaces and then shine a special light to check if the marks are still there after cleaning is done.

"We found a computer screen in the intensive care unit that was never being cleaned," he said.

Once hospital staff clarified to cleaners that disinfectant was safe to use on computer screens, Muller says the rate of cleaning and disinfecting shot up to 90 per cent or more.

"Regardless of whether it's their own environmental services team or an outsourced team, the buck still should stop with the facility," Muller said.