Comment on draft National Infection control guidelines

By Brian Clark

The recent publication of Draft National Infection Control Guidelines for public comment by the
National health and Medical Research Council (NHMRC) was a golden opportunity for the cleaning
industry to provide input into a document that will have a dramatic influence on cleaning in
Healthcare for the next 5 -10 years. Some of the recommendations in the draft reflect the lack of
understanding of cleaning and cleaning trends and have created considerable concern and
controversy, particularly within the carpet industry. While there was considerable emphasis on the
importance of environmental cleaning & selection of appropriate floorcoverings as infection control
measures, neither the cleaning nor the floorcovering industry were represented on the working
committee.

One of the earliest proponents of cleaning to control Infection was a practicing nurse named
Florence Nightingale. Her work and that of Joseph Lister, a pioneer in disinfection and asepsis
techniques, are enshrined in the annals of the global Infection control movement.

The importance of cleaning in infection control was again emphasised in 1974, with the publication
of ‘Hospital Hygiene’ by Isobel Maurer. Maurer’s commonsense approach to cleaning and
disinfection redefined disinfection policy and set the baseline for modern infection control practices.
One of the current proponents of the importance of cleaning in preventing infection in Healthcare is
Stephanie Dancer1. According to Dancer ' The introduction of additional cleaning services is easier
than improvements in hand-hygiene compliance.' and, most evocatively, ‘…there is little direct
evidence for the effectiveness of cleaning because it has never been afforded scientific status.’

Dancer’s second statement is echoed in these draft guidelines. Academic standards and science tend
to disappear, to be replaced by broad, unsubstantiated statements whenever cleaning is mentioned.

Carpet, in particular, cops a beating. Section C6.2.3 of the draft contains this statement: ‘' The use
of carpet can be controversial as it is perceived to be difficult to clean compared with hard floor
coverings'. Perceived? by whom? There are recommendations on page 165 of the draft as to where
carpet should not be considered, but there is no evidence provided to support this statement.

Furthermore, there is no evidence presented in the reference documents or in the draft guidelines,
which supports recommendations as to design and selection of soft floor coverings or cleaning of
soft floor coverings. In fact, there is not a single study in published literature to compare the impact
of on the rate of Hospital Acquired infection with hard versus soft floor coverings.

The draft guideline explains that hard flooring is ‘costing less, as disinfectant is less expensive than
steam cleaning, and steam cleaning may not be readily available.’ Hardly academic, verging on the
ridiculous and the terminology is incorrect. The terms ‘Steam Cleaning’ and ‘Shampooing’ are freely
interchanged in the document, completely ignoring the accepted industry terminology and the
Australian Standard AS/NZS 3733:1995, which classes ‘Shampooing’ and “Steam” cleaning (Hot
Water Extraction) as two distinct methods. ‘Shampooing’ is described as a ‘Surface Cleaning

1
Dancer, SJ. 'Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for hospital cleaning'.
Lancet Infect Dis 2008; 8: 101–13
method’2, while Hot Water Extraction is defined as a ‘Corrective or Restorative Cleaning Method’.
Both methods utilise a separate set of equipment, chemical and methodology. Incidentally,
shampooing methods & Bonnet buffing are similar methods and are not recommended on many
specialist floorcoverings in healthcare, while Bonnet Buffing has been associated with an outbreak of
aspergillosis in an HSCT unit.3

It should be noted that the reference above to ‘costing less’, or cost saving by cutting cleaning
services in an infection control context is not supported by literature that is referenced elsewhere in
the document. According to Dancer, in a UK hospital study 4 in which an MRSA outbreak was arrested
by increased cleaning, it was concluded that, in the long term, cost cutting on cleaning services is
neither cost-effective nor made sense.

Another statement, again in the context of carpet in hospitals, raises alarming implications for
exposure to risk and potential litigation, explains that ‘there may be occupational health and safety
issues relating to staff vacuuming when compared to mopping..’. The WH & S risks associated with
cleaning are different in every site and need to be individually assessed by Job Safety Analysis and
risk management programs, rather than by assumption. Each state and Territory publishes detailed
injury statistics for the cleaning industry and they should be consulted before including or publishing
statements relating to Workplace Health and Safety and Risk management. It could also be stated
that safety concerns should also be included with hard floor as there is a significantly increased risk
of slip and fall injuries on hard floor surfaces.

It may seem that the tone of this article is harsh, but it is not meant to be a criticism of the NHMRC
committee or the guidelines as a whole. Rather, it is the cleaning industry that is failing in its
responsibility to advance the science of cleaning and build a credible public image. It needs to stop
hiding in dark basement cubby holes and show itself as a trained, professional and essential industry.
Industry organisations need to think about building the future, to promote the need for, and even
fund, credible research.

Cleaning is an integral component of infection control, yet it is continually overlooked and rarely
consulted, except when it comes to cutting costs. The cost of proper cleaning in healthcare is
miniscule compared to the loss of life and quality of life and the ongoing treatment costs of infected
patients.

Overall, the industry needs to become experts in the science as well as the mechanics of their trade.
Until then, Cleaning will remain all too hard or maybe not that important in the eyes of those that
control the funding and set policy.

2
AS/NZS 3733:1995 Section 2, subsection 2.1.4 Guidelines page 7.
3
44) Gerson SL, Parker P, Jacobs MR, Creger R, Lazarus HM. Aspergillosis due to carpet contamination
[letter]. Infect Control Hosp Epidemiol 1994;15:221–3.
4
Rampling A, Wiseman S, Davis L, et al. Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus
aureus. J Hosp Infect 2001; 49: 109–16.