The maintenance of a clean environment is a fundamental principle of infection prevention and control (IPC) and every patient deserves to be treated and cared for in a clean, safe environment. In recent years, a contaminated healthcare environment has been considered by some IPC practitioners to have a role in infection acquisition, but the development of any infection is complex and will depend on a number of variables (Boyce et al, 2010; Dancer, 2014). Developing a healthcare-associated infection is a serious patient safety issue that not only is very costly for the healthcare setting concerned, but also greatly increases morbidity and mortality rates. Therefore, an understanding of all the modern methods to maintain IPC is necessary to provide an adequate and cost-effective service.
The extent to which the environment contributes to the transmission of pathogens and the level of cleanliness required to prevent infection is unknown. Historically, keeping the healthcare setting clean was viewed as an aesthetic measure, but today there is much debate and controversy around the benefits of a clean environment in promoting recovery from sickness and preventing infection. We know that prevention and control of infection is multifaceted, and interventions such as antimicrobial stewardship (promoting evidence-based prescribing of antibiotics) or standard and transmission-based precautions such as hand hygiene and isolation are supported by the literature. Nonetheless, when it comes to the clinical environment, its role in infection acquisition is hypothesised reactively from infection outbreak studies and pre- and post-intervention studies. Whether the general environment outside of these conditions contributes to, or is the cause of, infection acquisition is untested and therefore unknown.
Unfortunately, cleaning of the environment is not an exact science and it is difficult to measure effectiveness for service users. The insufficient literature available ultimately leaves IPC practitioners unsure of the everyday role of the clinical environment in the acquisition of infection. There is an incomplete understanding of whether the healthcare environment facilitates or causes the transmission of infection and therefore which are the best methods to clean it. This can lead to wide variations in clinical practice, which is also a patient safety issue.
Environmental contamination is considered to occur from pathogen transmission via healthcare workers' hands or directly from contact with colonised or infected patients. It is assumed that, within the chain of infection, the environment serves as the reservoir for those pathogens that are known to survive well in the environment. If cleaning is performed correctly, the environment will be cleaned effectively. However, because traditional manual cleaning methods depend on many human factors, extreme variations in quality between healthcare settings can exist.
To overcome this variability, and ultimately try to improve patient safety, innovative ways to manage environmental contamination and reduce cleaner bias have been created. These include the use of steam, ultraviolet light and hydrogen peroxide. It seems sometimes that the solution to inadequate cleaning is the implementation of these products via automated systems. The pressure from publicity following outbreaks and the potential for the media to blame these on cleaning can also cause healthcare settings to react and implement systems without evidence. The effects and contributions of automatic systems are causing huge debate and are only proven to be of benefit in reactive situations such as outbreaks or in the management of particular pathogens. Evidence that these automated methods alone will proactively prevent or control infection is limited, because the intervention is normally only ever implemented as part of a bundle in response to an outbreak of a particular pathogen. I feel that due to the current lack of evidence examining the clinical environment under normal everyday conditions, the literature is currently unable to demonstrate that routinely proactively reducing the environmental burden of pathogens in the clinical environment may translate into long-term tangible benefits for the service user.
Within the literature there are other interesting debates. They include questions such as: should the healthcare environment be routinely cleaned or disinfected? What materials should cleaning cloths be made from? What is the role of antimicrobial coatings and the effect of biofilms? The answers to these will help inform practice, but we must first try to understand the role of the environment in infection acquisition. The risk of cross-transmission will always be exacerbated by poorly designed, cluttered environments that experience a high turnover.
I would conclude that decisions on the best method for cleaning the environment should be made locally, based on professional advice from IPC practitioners. The advice should be based on the known pathogen or pathogens circulating and of concern, the clinical risk within the environment, and the immunity of the service user you are caring for. It is vital that we continue to seek answers to provide safe care for our service users today, particularly those who are increasingly more susceptible to infection, such as the patient infected with drug-resistant organisms in an acute intensive care setting. In some of these cases, prevention is the best or the only possible defence left to them.