Need for clarity

15th of September 2010
Need for clarity

How far does the role of the hospital cleaner extend and where do his or her responsibilities end? And can some cleaning tasks simply fall through the net? Ann Laffeaty finds out.

It is generally acknowledged that good cleaning and hygiene practices are vital in the healthcare industry to minimise the spread of healthcare-acquired infections. But do hospital cleaners actually know where their responsibilities begin and end? This issue was highlighted at the UK Association of Healthcare Cleaning Professionals’ 35th annual national conference in June.

Speaking at the event was Care Quality Commission HCAI specialist assessor Tracey Halladay who felt it was all too easy for some hospital cleaning tasks to slip through the net. “Patient bed spaces contain numerous items that need to be cleaned and decontaminated, but who is responsible for cleaning them?” she said. “And as for patient chairs, who checks them when the patient goes home?”

She showed photo examples of healthcare situations in which cleaning had been compromised such as cot sides that had been contaminated with faecal matter and damaged walls with peeling paint where dirt could collect. “Who is responsible for checking the cot sides – is it the cleaners or the nurses?” she said. “And where walls have been damaged, who should be responsible for reporting them?”

Bedside lockers were a particular case in point according to fellow speaker Dr Stephanie Dancer, consultant microbiologist at NHS Lanarkshire. “Cleaners are particularly averse to cleaning these because they don’t want to be accused of moving or stealing the patient’s belongings,” she said. “Consequently they don’t tend to clean the top of the bedside locker until the patient has left.”

Critical sites

However, lockers are among a number of critical hand touch sites around the patient’s bed that need particular attention from the cleaner, according to Dancer. She cited a study carried out in Glasgow where an extra cleaner was brought in specifically to clean these hand touch sites which also included bed rails, tray tables, call buttons and light switches. “One cleaner using a detergent-based cleaning agent was responsible for a 33 per cent reduction in aerobic colony counts,” she said. “Also reported was a 27 per cent reduction in new MRSA infections, saving the hospital €60,000 in a year.”

There are clear guidelines in place for cleaning bedside lockers in UK hospitals according to healthcare cleanliness lead of the National Patients Safety Agency Graham Jacob. “The Cleaning Specifications recommend that bedside lockers and tables be cleaned twice daily as a minimum, and it would be expected that such cleaning would be comprehensive,” he said. Jacob added that the person with overall responsibility for cleaning wards and patient areas in NHS hospitals depended on specific arrangements made within the trust.

“In some cases it will be the domestic cleaning team and in others the nursing staff or healthcare assistants, while for mechanical items such as ventilation shafts it may be the estates and facilities staff,” he said. “The key is that whatever arrangements are in place, these should be understood by all concerned and managerial arrangements should be in place to ensure that the correct procedures are being followed.”

He said hospital trusts should display signs advising who should be notified of failures or shortcomings. “Ultimately all staff, patients, visitors or anyone else in the hospital grounds or premises should notify any instances that have led to unacceptable levels of cleanliness.”
Carina Bale, national chair of the Association of Healthcare Cleaning Professionals, agrees everyone shares the responsibility of reporting cleaning breaches. “Where cleaning or hygiene has been compromised the individual witnessing the compromised situation should report it,” she said. “This includes patients and visitors as well as medical, nursing and domestic staff.”

She agreed that bedside lockers could be a problem area. “Cleaners are responsible for daily cleaning of bedside lockers, but this can on occasion be difficult as patients store personal items inside lockers and may try to restrict access. If they are successful, hygiene may be compromised.”

She confirmed nursing staff generally took care of cleaning direct patient equipment, but that their responsibility was not clear-cut. “At a local level where agreements have been put in place and specified training has been completed, cleaning staff may be responsible for cleaning direct patient equipment on behalf of nurses,” she said.

To add to the confusion the situation varies from country to country. In the Netherlands, for example, the overall responsibility for hospital cleaning lies either with the hospital hygienist or the facility services manager says ECJ’s Dutch correspondent Anton Duisterwinkel. However, cleaning tasks in the Netherlands are fairly well defined.

“The  division of tasks is well documented with the use of instruction cards,” he said. “Any areas that are unclear – such as medical equipment for example - are discussed by the cleaning company with the facility manager or the hospital hygienist, whoever is responsible.”

He said where cleaning or hygiene had been compromised, a cleaning company manager would report the irregularities to the facilities manager. “This can be either in a regular meeting or by immediately contacting the facility manager in serious cases,” he said.

Clear guidelines

In Poland there are clear guidelines over who should clean key hospital sites such as wards and corridors. “It is the epidemiologic nurse representing the healthcare infection department who is ultimately responsible,” said ECJ’s Poland correspondent Miko?aj Jankowiak “Every cleaning task in Polish hospitals is strictly defined so there should be no areas of confusion. But unfortunately there are no clear regulations regarding who should take care of secondary tasks such as patient transport or bio waste removal.

“Very often workers from outsourced companies are used for these tasks, which can create conflict and lead to disorganisation.”

Former infection control director at the NHS Mike Rollins agrees that there are definite gaps in the cleaning roles carried out in the healthcare sector. Rollins now works as an independent environmental consultant in the healthcare industry.

He says one major issue is the fact that no-one is monitoring the level and frequency of cleaning tasks carried out by nurses. “There is the assumption that someone has been there before you – but this can come back to bite everybody,” he said.

According to Rollins, expecting nurses to clean patient equipment is not always a satisfactory solution. “Nurses tend to use pre-medicated wipes with an antimicrobial action to attend to this task, but this is not very efficient,” he said. “And in a study carried out in Cardiff it was discovered that nurses could actually cause the spread of MRSA by using this technique.”

Hospital cleaning should always be a team effort according to Rollins. “Infection control is everybody’s responsibility. Infection control nurses have a lot of knowledge, but they can’t get around everybody effectively.”

One company that specialises in healthcare cleaning is the CK Group which offers tailor-made training programmes for domestic or infection control staff. The company has introduced a reporting system that helps to track ward cleaning regimes.

“Beds and other equipment are frequently moved from ward to ward and unless these are tracked, they could be missed from a cleaning cycle,” said managing director Ian Pether. “We tag these items with either a barcode or a physical tag and then load the information on to a computer.”

According to Pether it is the job of the infection control department to join up the dots and take ultimate responsibility for cleaning. But he agrees there are several grey areas regarding who is responsible for which healthcare cleaning task. “Although nurses tend to be responsible for cleaning patient equipment they don’t always see it as their job - they feel it is the responsibility of the cleaners,” he said. “And the fact that each hospital trust has a different policy complicates the matter.

Confusing for domestic staff

“Sometimes the nurse is responsible for cleaning the whole bed, for example, while sometimes they just clean the mattress and the cleaning staff clean the frame. It is very confusing for the domestic staff, especially if they move from one trust to another only to discover they are not doing the right job.”

Pether feels that the key to improved healthcare cleaning lies in placing a higher value on the role of the cleaning staff. “A cleaner has just as much responsibility for saving someone’s life as a doctor or a nurse since they help to control the rate of infections,” he said. “We are paying them a minimum wage but we expect them to do a spectacular job – it just doesn’t add up.”

Rollins agrees with this view and adds that there is a need to invest more heavily in staff training. “Our cleaning staff should be valued as competent technicians who have a vital role in protecting our patients,” he said. “But we pay them very poorly which means they disappear as soon as they are offered a better job.

“There is a generally-held prejudice that cleaning staff are just numbers and not intelligent people, but there are a lot of passionate people out there who do their job because they care.”


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