The cleanliness link

15th of September 2010

Over four million patients are estimated to acquire a healthcare-associated infection in the EU each year. Much of the blame for increases has been targeted at 'dirty' hospitals. Here, Paul Weaving, lead nurse infection prevention and control at the Royal Marsden NHS Foundation Trust in the UK, writes about the perceived links between cleanliness and the risk of infection.

Approximately 4,100,000 patients are estimated to acquire a healthcare-associated infection in the European Union every year. Infections cause patients distress, discomfort, disability and death. The number of deaths occurring as the direct consequence of these infections is estimated to be at least 37,000. Not surprisingly the risk of acquiring an infection while in hospital is of great concern to many patients, and there is much media coverage of so-called 'superbugs' such as Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant organisms.

In the UK much of the blame for perceived increases in hospital infections in the late 1990s and early 2000s was targeted at 'dirty' hospitals, and the popular impression, reflected in much of the media, was that infection rates in the National Health Service (NHS) had increased as the cleanliness of hospitals had declined, because cost pressures and other factors had caused less emphasis to be placed on domestic services, resulting in lower standards. Initiatives intended to combat healthcare-associated infection reinforced this impression with titles such as Towards Cleaner Hospitals and Lower Rates of Infection and A Matron’s Charter: An Action Plan for Cleaner Hospitals.

It is worth noting that these initiatives, combined with other measures such as increasing the profile of infection prevention within hospitals by insisting that there is a director of infection prevention and control in every NHS hospital trust who reports directly to the board and chief executive, and a renewed focus on safe practice in healthcare interventions, have been successful. Clostridium difficile and MRSA bloodstream infections are reported by every NHS hospital trust in England and there have been significant reductions in the number of both in recent years.

However the broad scope of these initiatives makes it difficult to ascertain the impact of any one factor. So how much does the amount and effectiveness of the cleaning carried out in a healthcare environment contribute to or reduce the likelihood of a patient in that environment acquiring an infection?

Most people will feel that a clean environment must be safer than a less clean one but proving it, or even demonstrating a significant link, can be difficult. This is partly because it is always difficult to prove you have prevented something (how do you know that any particular patient would have got an infection if your cleaning regime had been less strict?) and partly because whether or not an individual gets an infection depends on many factors.

These include their own susceptibility to infection (which is itself dependent on factors such as age and medical condition);  their exposure to microorganisms capable of causing an infection; medicines or invasive devices being used in their treatment; and, probably most significantly, how well infection prevention and control is embedded in the practice of the people caring for them. Studies have been carried out to try and establish a link between numbers of infections acquired and either the level of cleaning input or the observed cleanliness of the environment, but definitive evidence is hard to come by.

Reduce the spread of pathogens

Nevertheless despite the lack of definitive evidence of a link between the risk of infection and the cleanliness of the healthcare environment, it is generally accepted that one exists. The World Health Organisation states that “adequate environmental cleaning can help reduce the spread of some pathogens during healthcare”, while the Epic2 guidelines (a set of recommendations for infection prevention and control commissioned by the English Department of Health and based on a thorough review of the available evidence) observe that there is “a body of clinical evidence, derived from case reports and outbreak investigations, which suggested an association between poor environmental hygiene and the transmission of microorganisms causing healthcare-associated infections in hospital”.

In addition, patients and other members of the public will often assume that there is a link and will expect a hospital, or any other premises used for healthcare, to be clean. In England there is now a statutory obligation for healthcare providers to ensure this is the case. In order to register as a provider of health or social care, all such organisations have to declare they comply with the criteria detailed in the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infections and related guidance (often referred to as the Hygiene Code). The second criterion of this code is that the organisation “Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections”.

Having concluded that healthcare premises should be clean, the next step is to look at what this actually means. The guidance for fulfilling the Hygiene Code criterion above focuses on ensuring that organisational structures such as policies and a designated lead person for cleaning are in place rather than giving details of expected levels of cleaning input or stating an expected outcome.

More detail can be found in the Revised Healthcare Cleaning Manual published for the National Health Service in England by the National Patient Safety Agency (NPSA), which provides a wealth of information, including model infection control guidance for staff with cleaning responsibilities, method statements for individual cleaning tasks and stating which of these tasks should be carried out by cleaning staff and which by healthcare staff.

This last can be particularly useful because there will be items of specialist equipment in the healthcare environment that cleaning staff without specialist knowledge may feel unhappy about handling. Even when cleaning this equipment is straightforward, items such as drip stands or blood pressure monitors will often be in use when cleaning staff are working so it is important it's explicit who has responsibility for cleaning these items between episodes of use (the Epic2 guidance referred to above states that “Shared equipment used in the clinical environment must be decontaminated appropriately after each use”).

Useful as it is, the Cleaning Manual still focuses on input rather than output. For information on how to assess output we can look to another NPSA publication, the national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes. This gives further guidance on how to achieve high standards of cleanliness, some suggestions for identifying areas of relative risk (in terms of the likelihood of patients in different clinical environments acquiring an infection), but stresses that the single most important factor to focus on is the outcome – how clean the premises are – and provides a framework for monitoring and auditing cleanliness in these areas.

The risk of infection, and therefore the level of cleaning required, in any particular area will depend on the vulnerability of the patients cared for in that area and the procedures that are undertaken in that area. Very high risk areas therefore include operating theatres and intensive care units, and other areas where invasive procedures are carried out or patients have impaired immune systems such as transplant units or special care baby units. These areas require frequent intensive cleaning to the highest standards and should be audited every week.

Frequent auditing

Bathrooms, kitchens and other internal areas that are adjacent to very high risk areas should be cleaned to the same standard and audited as frequently. High risk areas such as general wards and adjacent areas require regular, frequent cleaning, with spot cleaning between scheduled activities if required, and should be audited at least monthly initially. This can reduced to two-monthly if the lead manager for cleaning and the infection prevention team are satisfied that consistently high standards are being maintained, and will continue to be maintained if the frequency of audit is reduced.

It is worth bearing in mind that while one of the functions of audit is to provide a record of the cleaning standard achieved and so provide assurance that required standards are being met, the most important function is to maintain and improve standards. Results of cleaning audits must therefore be fed back to the cleaning and clinical staff in the area being audited so that faults can be promptly rectified (and hopefully, not be repeated) and good practice recognised and acknowledged.

Non-patient areas should also be included in cleaning and audit regimes. Pathology laboratories and mortuaries are regarded as posing a potential risk to the staff who work in them and should also be kept clean for aesthetic reasons, but the audits may be as infrequent as once every three months.

Audits traditionally take the form of a visual inspection, ie, the area inspected should be visibly clean. The NPSA lists 49 different elements to be inspected as part of each audit, the majority of which it states should be “visibly clean with no blood and body substances, dust, dirt, debris, adhesive tape, stains or spillages”. In most circumstances this may well be adequate, but new technologies are now coming onto the market that detect the level of microbial contamination on even visibly clean surfaces, and in the future these may provide the possibility of an objective assessment of cleanliness.

Infections preventable

In conclusion then we can say that recent experience in the UK and elsewhere has shown that many of the healthcare-associated infections which may previously have been regarded as inevitable are preventable through the application of a programme of infection prevention measures. While it may not be possible to quantify the degree to which cleaning helps prevent infection, it must be part of every healthcare provider’s infection prevention regime. The acceptable standard of cleanliness required will be based on the risk of a patient in any particular clinical area acquiring an infection, which will also be used to determine the frequency with which each area is audited to ensure that the designated standard is being met.

Patients should expect to be cared for in an environment that is clean and fit for purpose. The contribution of cleaning, and of the people carrying it out, to the patient experience must not be underestimated.


•Department of Health (2010a) The Health and Social Care Act 2008:  Code of Practice for health and adult social care on the prevention and control of infections and related guidance. Department of Health. London. Available at

•National Patient Safety Agency (2007) The National Specifications for Cleanliness in the NHS: a framework for setting and measuring performance outcomes. National Patient Safety Agency. London. Available at

•National Patient Safety Agency (2009) The Revised Healthcare Cleaning Manual. National Patient Safety Agency. London. Available at

•Pratt, RJ, Pellowe, CM, Wilson, JA, Loveday, HP, Harper, PJ, Jones, SRLJ, McDougall, C and Wilcox MH (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 65S, S1-S64. Available at


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