Infection prevention and control is essential for patient care in healthcare settings and maintaining a clean hospital environment plays a vital role in this. Cleaning and environmental disinfection is a critical element of the intervention package required to reduce hospital-acquired infections. The Health and Social Care Act 2008 corroborates that effective cleaning is essential for infection prevention and control and states the requirement for healthcare facilities to ‘provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections’. This was particularly evident during the SARS-CoV-2 pandemic.
Effective cleaning is reliant upon good practice and technique. Previous work in hospitals has shown cleaners’ technique can have a significant impact on the efficacy of the clean, reducing contamination of environmental sites in hospitals (Hota et al., (2009). That research found that persistent environmental contamination reflects personnel, rather than procedure or product, failures.
Well-trained and conscientious cleaners are critical for cleaning and disinfection tasks to be performed effectively, and therefore, maintaining a healthy and motivated cleaning workforce is critical for the function of all healthcare facilities.
Education of cleaners and observation interventions are associated with improved cleanliness and less hospital environmental contamination (Hota et al., (2009). Cleaning, however, is a physically demanding and repetitive task, often with low levels of professional recognition and pay, and feelings of lack of dignity and respect afforded by others in their workplace (Equality and Human Rights Commission, 2014). To maintain high levels of engagement and therefore environmental cleanliness and infection control in healthcare settings, it is critical we support and look after the professional cleaners and those undertaking cleaning and disinfection tasks.
Cleaners in healthcare settings face daily health and safety challenges including manual handling, wet work, working at height and working with chemicals.1, 2 Alongside protecting hands and skin, preventing splashes to eyes and protecting against musculoskeletal disorders, cleaners and their supervisors need to consider occupational respiratory health. Respiratory exposure to dusts, airborne microorganisms and chemical vapours can potentially result in irritant and/or allergic responses of the respiratory system.
An excess of asthma and respiratory symptoms have been reported in studies of healthcare workers and domestic cleaners (Robinson et al., 2017), and there is an increased risk of new-onset asthma for nurses who undertake cleaning or disinfection tasks (Romero Starke et al., 2021). Cleaning products are amongst one of the most cited causative agents of physician-diagnosed occupational asthma reported by doctors participating in the SWORD scheme within The Health and Occupation Reporting (THOR) network. 3
A broad spectrum of cleaning products have been reported to cause respiratory symptoms, including chlorine-liberating agents and bleaches (Robinson et al., 2017). Scientists at the Health and Safety Executive (HSE) have been working with several NHS Trusts and Independent healthcare providers to understand the health and safety challenges faced by those undertaking cleaning tasks in hospitals. This research had a particular interest in how occupational respiratory exposure to chemical disinfectant products was controlled in hospitals and what opportunities existed to reduce that potential exposure risk.
Thorough risk assessment is imperative to characterise the hazards associated with cleaning and disinfection tasks in a healthcare setting. 4 As part of this assessment, there are several factors which ought to be considered first.
Consider not only the hazards and risks associated with undertaking the disinfection task but also the infection risk. Assessing the infection risk for individual areas of the healthcare setting, rather than an overarching approach to whole wards or hospitals, will enable targeted control measures to be implemented in individual areas. For example, an exposure control measure which works in a public waiting room may not be appropriate for an operating theatre.
Consider the infection risk of that area; does the area need to be disinfected or could detergent and water be used to clean the area instead? If disinfection is required, consider the frequency of disinfection and the concentration of the product being used. Obtaining a balance between disinfection frequency and/or concentration without compromising infection control and the level of exposure risk for cleaners is key.
Consider the choice of disinfectant product to balance the infection control need with potential cleaner operator exposure. Bacterial resistance to disinfectants including quaternary ammonium compounds, phenols, chlorine and glutaraldehyde has been documented (Chapman, 2003). There are also examples of co-resistant to disinfectants and antibiotics, and how disinfection by-products can promote antibiotic resistance gene transfer, which may exacerbate the issue of multidrug antibiotic resistance in healthcare (Tong et al., 2021).
Moreover, some disinfectants, such as chlorine, are corrosive and damage fixtures and fittings. It is therefore critical that disinfectants are not overused to maintain their efficacy and the physical integrity of hospital fixtures and fittings. Users should also consider how the product is applied; spray application of chemical disinfectant products may increase the potential for respiratory exposure.
Once these factors have been considered, identify control measures to mitigate exposure to use of the selected disinfectant chemical. Following the Hierarchy of Control, there are a number of control options to mitigate respiratory exposure to chemical disinfectants which may include:
✓ Considering the choice of chemical disinfection product to eliminate or reduce the hazard is an option, but the HSE research recognised that here there can be discrepancies between selecting the correct disinfectant product for infection control purposes and a product which will reduce the risk of respiratory exposure in those cleaners being asked to use that product.
✓ Ensure adequate ventilation; all workplaces need an adequate supply of fresh air; this can be natural ventilation, from doors, windows, etc. or controlled, where air is supplied and/or removed by a powered fan.
✓ Consider increasing the level of ventilation during use of chemicals or where there is a risk of respiratory exposure to harmful substances.
✓ Use of appropriate Respiratory Protective Equipment (RPE), designed to protect against exposure to chemical vapours and fumes.
At a strategic level, increased effective communication between infection prevention and control practitioners, cleaners, and estates is required, for example, invitations to attend infection control meetings and having a meaningful voice in the selection of chemical disinfection products and how they are to be used.
The HSE research identified that in most healthcare organisations, respectful attitudes towards cleaning professionals could be enhanced. There needs to be an appreciation of the importance of the cleaning and disinfection and the critical role cleaners play as part of the professional healthcare team. Increased communication and mutual appreciation by clinicians and cleaners of the roles they each play is vital in maintaining a clean and safe environment for staff and patients.
Notes
COSHH and cleaners – key messages – COSHH (hse.gov.uk).
Cleaning industry health and safety (hse.gov.uk).
Work-related asthma in Great Britain 2022 (hse.gov.uk).
Risk assessment: Steps needed to manage risk – HSE.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work described here was funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the author alone and do not necessarily reflect HSE policy.
ORCID iD
References
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