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Friday, June 15, 2012

Complexities in cleaning a paediatric hospital environment


Those of us working to prevent infections in paediatric hospitals typically view the environment with a high degree of suspicion.  A bundle of factors predispose infants and young children to acquire infections from organisms present on surfaces.  Their relatively naïve immune systems and lack of inhibition for environmental oral interaction, combined with total dependence on others for care and a tendency for us to surround them with toys and other objects for distraction, development and amusement, align the odds strongly in favour of transmission. 
The epidemiology of infections in paediatric hospitals differs from adult hospitals.  Health care associated respiratory and gastrointestinal viral infections are far more common than so called “super bugs”.  These agents are viable from environmental surfaces from hours to weeks.  When you consider how often the side rail of a crib can be inoculated with pathogens in the context of a baby with diarrhea requiring frequent diaper changes, the risk for transmission becomes very clear.  You cannot safely leave the side rail down while removing gloves and cleaning your hands, particularly when you have a heavily loaded diaper to contend with at the same time.  Diapers of sick children need to be weighed and cannot be immediately discarded, resulting in even more opportunities for transmission.     
The recent focus on Clostridium difficile infection (CDI) has reinforced what we think we know about the environment in paediatrics and has highlighted what we don’t know.  The morbidity and mortality of CDI is much lower in children than adults and yet the rate of infection when directly compared (which epidemiologists know we should not do), is generally higher.  We know that a larger proportion of infants and very young children are asymptomatically colonized with C. difficile.  For that reason, it is rare to test infants less than 12 months of age for that agent as a cause of diarrhea.  Recent studies suggest that C. difficile may be a more important pathogen in children than previously appreciated.   Until that is better understood, we need to focus on what we do know; that C. difficile may be present in the stool of more than 60% of infants and that it may easily contaminate the environment putting certain paediatric populations at risk for infection.  That knowledge places even greater importance on having sound cleaning practices in place. 
Achieving optimal cleaning requires an understanding of the complex interplay of chemistry, human factors and behavioural science involved in cleaning processes.  We are attempting to understand that better.  A recent quality improvement project (Matlow, Wray & Richardson, Am J Infect Control, 2012 Apr;40(3):260-2) has contributed to our understanding by highlighting the importance of the attitudes and beliefs of cleaning staff and how their attitudes and beliefs shape both their intent and actual attention to environmental cleaning.  We learned that it was largely their internal desire to do a good job, with underlying thoughts of “what if it were my child in that bed” that drove their practice.  We also learned that they did not always feel appreciated by staff who took for granted the work that they so highly valued.  From a practical perspective, we learned that cleaning staff, professional staff, and infection prevention and control staff had varied opinions regarding which surfaces are frequently handled and therefore require consistent attention.  We also better understand some of the tensions between family centered care and achieving high standards of cleanliness.  Families of patients are integral to the care of their children.  They are nearly always present.  While present, they bring belongings from home, needed for extended lengths of time.  We don’t always have adequate storage space and so personal belongings become clutter and impede cleaning. 
Similar findings arose from our “housekeeper for a day” program (Streitenberger, et al, 2012, poster; 8th Annual Paediatric Patient Safety Symposium) in which assorted hospital staff were partnered with a member of our cleaning staff to learn from and to work with them to clean patient rooms.  One medical leader commented that he felt immediately “invisible” to professional staff but he became more accessible to patients and families who seemed pleased to see him and perhaps more willing to initiate conversation than he was accustomed to in his usual role.  One senior leader became aware of the pride and diligence of the staff member with whom he was partnered.  She was reluctant to let him do the cleaning; not because it was a job beneath his usual position but because he wouldn't do it well enough and she would have to clean up behind him.  All of the participants gained more appreciation for the competing demands and interruptions of the cleaning role and better understood how physically demanding it could be.  Most importantly, staff could all identify simple ways in which they could make cleaning easier and how they could include cleaning staff as team members with a common goal.  At least short term, there was less clutter, better communication, fewer unnecessary interruptions, and a renewed sense of pride among cleaning staff following the program.  We intend to include this program as part of our best practice for optimal cleaning. 
On the surface (no pun intended), cleaning appears to be a straightforward task once you choose the right tools.  The complexity is only revealed when all of the many drivers associated with the practice are taken into account.  It should never surprise us that what seems to be straight forward is rarely that way in the complex environments in which we work.

Rick Wray

Rick Wray has worked at The Hospital for Sick Children (SickKids) for 30 years, the last 16 of which have been in Infection Prevention and Control.  Rick is currently the Director of Quality, Safety and Infection Prevention and Control.   Rick has been an active member in the Canadian Infection Control Community and has been involved with CHICA-Canada both as a board member and president.

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