CLEANLINESS AND INFECTION CONTROL IN HOSPITALS There is a body of clinical evidence which suggests an association between envir onmental

hygiene and Health Care Associated Infection (HCAI; defined as any infe ction caused by an infection agent acquired as a consequence of the patients trea tment or which is acquired by healthcare workers in the course of their duties). No one claims that lack of cleanliness is the only factor behind HCAI, nor that cleanliness is the only solution. However, a clean environment is the best platf orm to tackle HCAIs. the connection between environmental cleaning and incidences of HCAI the connection between the quality of cleaning and how it is carried out, whethe r in-house or outsourced Cleanliness and HCAI Its worth noting that there are three categories of clean surfaces Visibly clean: surfaces free from obvious visual dirt and soil Chemically clean: surfaces free from organic and inorganic residues Microbiologically clean: surfaces having a microbial load of an acceptable level The issue of Those that Those that Those that hospital infection control is about connections: are proven are likely are disputed

HCAI is related to a range of factors: Hand Hygiene Environmental cleanliness Antibiotic use Patient profile and mobility Hospital occupancy rate About 1.4 million people worldwide are suffering from HCAI. To minimize this, ce rtain measures are necessary: Cleaning should be subjected to strict in-house Quality Control; Quality Analysi s should be ascertained by authorized bodies Patients should comply with the following rules: - Regular hand washing - Should not contribute to clutter - Survey the room, the bathroom and the bed for visual cleanliness Visitors should comply with the following rules: - Refrain from sitting on the bed or handle equipment - Should not use patients bathroom - Should not visit if they have had any symptoms within the last three days, inc luding nausea, vomiting, diarrhea or uncontrolled cough or rash - Should not bring outside food to the patients The hospital should supervise the cleaning process in accordance with the nation al or international cleaning standard and procedure IN-HOUSE CLEANING VERSUS CONTRACTING OUT In advanced countries, the choice between these options is a hotly debated subje ct. For every option, I will list the main arguments of those for it and those a gainst. In lesser advanced countries of the Middle East, this problem is hardly an issue. I will describe the situation as I see it. In both cases, an assessmen t will be recommended. Analysis in advanced countries

General Considerations Cleaning has not yet been afforded scientific status Measurement of cleanliness is a contested area Infection control depends on a variety of different measures and policies running and applied concurrently It is difficult to isolate and measure the effectiveness of cleaning in order to prevent HCAI Hospital cleaners should perceive themselves to be different from more general building cleaners In-house Cleaning: factors to be considered It is relatively easy to get additional cleaning done during an outbreak. The level of integration between domestic and clinical staff is fairly high. In an integrated work place, the opportunity to move from one rung of the job ladder to the other exists. This allows both the employer and the individual employee to benefit. It is difficult to recruit and retain cleaners. Reasons being low pay, level of hard work and discomfort working in a hospital environment. The division of staff into clinical and nonclinical groups can create institutio nal apartheid which might be detrimental to staff morale and the patients. The hierarchy within hospitals is headed by personnel who care (doctors and their assistants who may be nurses or technicians), followed by those who care and heal (nurses, therapists and attendants). At the bottom of the hierarchy come those responsible for hygiene (cleaners, sterilizers and launderers) and health maintenance (food services). Outsourcing: factors to be considered It improves control and monitoring of the level and quality of service through the obligation to formally specify a contractor for services. It is cheaper on average than services provided in-house. Maximum savings is possible by tendering out services, like cleaning, laundry and catering. Might make it difficult for managers and matrons to control cleaning. Nurses might find themselves unable to direct private sector cleaners. Ruptures any job ladder connecting skilled cleaners to a position higher than janitorial staff. If contractors dont recruit and retain, if they dont provide proper training to their staff, if they dont have an appropriate skill mix, if they dont pay the g oing rate; service quality will be inferior to that of in-house cleaning. Replaces public service with private gain. Contracts cannot be readily altered to respond to a change in infection hazard requirements. Assessment Hospital management should carefully assess the pros and cons of both options an d decide upon the course to be taken AND DECIDE ON THE THIRD OPTION. Prime consideration should be given to the standard of healthcare offered and to the control of infection especially HCAI. Saving money, though important, shoul d not be the main goal. Analysis in developing countries

Status Quo In countries of the Middle East, the factors determining assessment are drastica lly different from that of developed countries. Hence, I did not find it useful to discuss each option on the lines of developed countries; but rather to pinpoi nt the general conditions prevailing in most of the lesser developed Middle East countries. Awareness of a clean hospital environment and of healthcare associated infections (HCAI) is nonexistent amongst administrators or at best of very lo w priority. The hospital administrators are not well-trained, inefficient and overwhelmed with their day-to-day affairs to pay attention to matters of cleaning. The health establishments consider cleaning to be peripheral as compared to major problems of healthcare. National cleaning standards and codes of practice are unavailable. HCAIs are not diagnosed, never documented and rarely assessed. The management does not take the effort to understand the relationship of cleanliness to the incidences of HCAI nor to the standard of cleaning provisi on. Standard of cleanliness amongst the people at large is very low. Patients and their visitors are not an exception. Hospital cleaning is overwhelmingly performed by working class women who are not provided with any training. Their cleaning knowledge is limited to wh at they carry out in their own homes. Moreover, they are poorly paid and rated very low in the hierarchy of tasks carried out by women within the hospital. There are no private sector contracting companies specializing in hospital cleaning as they consider this activity to be unrewarding financially.

DR. PRADNYA MURBADKAR.