Right approach: improvement in cleaning and disinfection of medical equipment in use – Sheikh Shakhbout Medical City (SSMC) experience

Abstract

Background

In 2021, Sheikh Shakhbout Medical City (SSMC) faced an increase in hospital-onset multidrug-resistant organisms; Candida auris increased to 1.4 per 1000 patient days, within critical care areas. This rise prompted the infection prevention and control team to enhance cleaning and disinfection practices, aiming to reduce infection transmission risks. The focus was on adherence to a structured cleaning protocol, which included high standards of equipment disinfection, regular audits and the establishment of roles and responsibilities for staff involved in cleaning and disinfection.

Methods

To improve compliance, the team initiated regular audits starting in May 2021, which revealed an initial compliance rate of 49%. These audits assessed adherence to infection control standards for equipment cleaning, including the thoroughness of cleaning for high-touch areas on medical devices. A multidisciplinary team met regularly to develop a risk-based categorisation system for equipment, providing clear guidelines on cleaning practices. In parallel, targeted training programmes were rolled out for environmental service personnel and nurses. By October 2023, a tagging system was implemented to streamline protocols and improve adherence by marking equipment with specific cleaning instructions.

Results

The audits showed progressive improvements in compliance, reaching a peak of 100% by late 2022. However, staffing changes and turnovers affected adherence, with a temporary drop to 78% compliance in January 2023. The introduction of the tagging system in October 2023 contributed to a stabilised compliance rate exceeding 90% by early 2024, demonstrating the effectiveness of systematic interventions. The hospital-onset multidrug-resistant organism “C. auris” decreased to 0.5 per 1000 patient days in 2024.

Discussion

Transferring cleaning responsibilities and implementing new tools emphasised the need for continuous training and communication. The risk-based categorisation and tagging systems were particularly effective in reinforcing cleaning protocols, even as staff turnover posed challenges.

Conclusions

Through these strategic initiatives, SSMC significantly improved the cleaning and disinfection of medical equipment in critical care, reducing the presence of hospital-onset C. auris and enhancing patient safety. Ongoing evaluation and adaptation remain vital for sustaining high standards in infection control.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Cleaning and disinfection of medical equipment are critical for preventing healthcare-associated infections. However, compliance with cleaning protocols is often inconsistent, leading to a higher risk transmission of multidrug-resistant organisms, such as Candida auris.

WHAT THIS STUDY ADDS

• This study demonstrates the effectiveness of structured Plan, Do, Check, Act cycles, risk-based equipment categorisation and tagging systems in improving cleaning protocol compliance and reducing hospital-onset C. auris rates.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings emphasise the importance of systematic interventions and innovative solutions in enhancing infection prevention. This approach could guide policy and practice improvements in healthcare facilities worldwide.

Introduction

Healthcare-associated infections affect hundreds of millions of people worldwide and lead to significant morbidity, mortality and financial loss for healthcare facilities. Infection control programmes are designed to protect patients, visitors and staff from acquiring or transmitting infections within healthcare facilities.¹

Several factors affect the link between environmental contamination and the risk of the acquisition of pathogens in healthcare. These include the pathogen’s resilience, virulence, ease of transfer, ability to colonise or infect patients, capacity for biofilm formation and tolerance to antiseptics and disinfectants or surface materials. Environmental surfaces such as countertops, sinks, curtains, bedrails, bedside tables, nurse call controls and patient-used equipment like syringe pumps, infusion pumps and monitors can serve as reservoirs for microorganisms that then may be transmitted to patients or healthcare workers.¹

Equipment cleaning and disinfection is an important component of infection prevention and control (IPC) programmes in healthcare facilities. It is essential for reducing the transmission of infectious pathogens to patients. Failure to properly clean and disinfect medical equipment carries not only the risk associated with a breach of host barriers but also the risk for person-to-person transmission (eg, hepatitis B virus) and transmission of environmental pathogens, for example, Pseudomonas aeruginosa.²

There have been published reports of low standards of cleaning and disinfection of equipment in hospitals around the world.² In addition, it remains unclear whether cleaning and disinfection of equipment is more effective when assigned to clinical or non-clinical staff. There are no international or national United Arab Emirates (UAE) recommendations about which staff should be responsible for cleaning medical equipment in use by patients. Cleaning and disinfection of equipment in use are often assigned to clinical staff (eg, nursing) because of the risk of non-clinical staff inadvertently causing alterations to settings of medical equipment.

Sheikh Shakhbout Medical City (SSMC) is the largest teaching hospital in the UAE with a current capacity of 560 beds in total. It hosts all major specialties and a national burns unit. It has large medical, surgical, cardiac, paediatric, neonatal and burns intensive care units. In the first quarter of 2021, there was a notable rise in the occurrence of hospital-onset Candida auris (1.4 per 1000 patient days) within critical care areas. This posed a significant challenge for IPC teams at SSMC. In response, the IPC team and stakeholders implemented a series of measures to combat the spread of these organisms and reduce the incidents of hospital-onset C. auris. One of the key strategies employed by the IPC team was conducting audits for environment and equipment cleaning and disinfection after patient discharge. These audits aimed to assess the effectiveness of the cleaning and disinfection processes in place and identify any gaps or areas for improvement. Regular audits were essential to ensure that the critical care areas maintained a high standard of cleanliness and reduced the risk of multidrug-resistant organism transmission.

In 2021, SSMC approved a policy on cleaning and disinfection procedures in high, moderate and low-risk areas aimed to ensure a clean and safe environment for patient care and emphasised specific guidelines for the cleaning and disinfection of patient care equipment. The policy consisted of two main provisions: (1) Environmental services personnel should not clean or disinfect patient care equipment that is in use (connected to patients). (2) The assigned nurse should be responsible for cleaning all bedside equipment connected to patients. This approach aimed to establish a clear line of responsibility and ensure that equipment used directly in patient care receives regular cleaning and disinfection.

In May 2021, a specific cleaning and disinfection audit targeted the medical equipment that was actively being used in the critical care areas at SSMC. The purpose of this audit was to evaluate the compliance of clinical staff in adhering to the recommended cleaning and disinfection policy and protocol for equipment.

Audit methodology

Audits are essential for ensuring effective cleaning and disinfection in healthcare facilities, preventing infections and maintaining a safe environment. In audits, visual assessment is commonly used to inspect equipment and surrounding areas for signs of inadequate cleaning. More advanced methods include using fluorescent powder and ultraviolet (UV) light. Auditors apply the powder before cleaning and inspect the area under UV light afterwards. The powder fluoresces under UV light, highlighting any missed spots or inadequate cleaning, thus indicating areas that need further attention.³

At SSMC, the IPC team conducts monthly audits in all critical care areas to assess the effectiveness of cleaning and disinfection. These audits use fluorescent powder and UV light. An audit tool was developed to streamline data analysis and facilitate the sharing of results. Each audit spans 2 days. On the first day, the auditor (infection preventionist) selects five high-touch areas on equipment, such as buttons, switches, handles and touch screens, and applies fluorescent powder to these spots. On the second day, the auditor inspects the equipment with a UV light. Any remaining fluorescent powder glows under the UV light, revealing areas that were not adequately cleaned (Ng, 2014).

The auditor recorded the results, including the areas that were audited, and any missed areas that were identified. This data was analysed to identify areas needing improvement. The findings were then shared with stakeholders to implement necessary changes and enhance cleaning and disinfection procedures.

Baseline data

The initial audit results in May 2021 revealed a compliance rate of 49%. This means that only 49% of the medical equipment being used in critical care areas met the established cleaning and disinfection standards. The audit findings served as a wake-up call, emphasising the pressing need for improvement in the cleaning and disinfection practices related to medical equipment in use.

Learning from others’ experiences

Learning from others’ experiences is a crucial aspect of any investigation, quality improvement or research process. In the case of the SSMC, the IPC team recognised the importance of gathering insights from other facilities to enhance the SSMC procedures and methods. To achieve this, the team conducted a thorough investigation that involved cross-referencing with multiple facilities in Abu Dhabi.

By reaching out to other facilities, the SSMC IPC team aimed to learn from the knowledge and experiences of those who had faced similar challenges. During their review, the SSMC IPC team made an interesting discovery. They found that none of the facilities had established a monitoring system for cleaning and disinfecting equipment in use. The absence of a monitoring system in other facilities may have indicated a potential gap or oversight in the overall cleanliness and disinfection processes for equipment that is connected to patients. Therefore, the SSMC IPC team worked on the opportunity of developing a more robust monitoring system tailored to their specific needs to enhance their cleaning and disinfection protocols.

Call for action

(1st PDCA cycle)

In June 2021, the SSMC IPC team, along with nurse leaders and clinical resource nurses, took several measures to enhance compliance with the cleaning and disinfection of equipment in use protocols in critical care areas. (1) The IPC team communicated the importance of equipment cleaning and disinfection through SBAR (Situation, Background, Assessment and Recommendation) communication, facilitated by the chief nursing officer. This method allowed a concise and structured approach to convey information and reinforce compliance. (2) A daily huddle was organised, bringing together nurses involved in critical care areas. During these huddles, the importance of equipment cleaning and disinfection was emphasised, and any challenges or concerns were addressed collaboratively. (3) Regular reminders were shared through email about equipment cleaning and disinfection policies. These reminders served as a constant reinforcement of the expectations and guidelines, ensuring that they remained top of mind. (4) A system change was implemented in the electronic medical record, in partnership with the application specialist, to facilitate the accurate and efficient recording of cleaning activities, thereby ensuring accountability and easy access to data. (5) Several education sessions were conducted to familiarise healthcare staff with the equipment manufacturer’s user manual. By ensuring that nurses had a clear understanding of the manufacturer’s guidelines, the IPC team aimed to improve adherence to cleaning protocols.

Through these various strategies, the IPC team, nurse leaders and clinical resource nurses collaborated to create a culture of compliance and accountability in critical care areas. By reinforcing the importance of equipment cleaning and disinfection, implementing system changes and providing education and support, the team aimed to reduce the risk of hospital-onset C. auris within critical care areas to ensure a safe environment for patients and healthcare professionals.

Despite multiple attempts to improve the cleaning and disinfection of medical equipment connected to patients, the desired level of compliance was not consistently achieved. Despite the initial improvement to 94% compliance in quarter three of 2021, the subsequent quarter saw a decline to 40%. From May to December 2021, the average compliance with equipment cleaning and disinfection in critical care areas stood at 60%. The summary of the 1st PDCA cycle shown in table 1.

Table 1. Awareness and compliance improvement through structured communication and audits.

PDCA cycle	Plan	Do	Check	Act
Cycle 1 (June 2021)	Identify compliance gaps and raise awareness of cleaning standards.	Implement daily reminders, structured team huddles and SBAR communication through nurse leaders.	Conduct regular audits to monitor cleaning adherence.	Improve compliance through feedback loops and reminders, fostering a culture of accountability.

SBAR, Situation, Background, Assessment and Recommendation.

2nd PDCA cycle

In January 2022, a multidisciplinary team (MDT) was formed to address non-compliance with equipment cleaning and disinfection protocols. The team included nurse leaders, the IPC team, the biomedical department, support services and clinical resource nurses.

During the reflection process, the team identified the nursing shortage and high patient acuity in the critical care areas at SSMC as the main contributing factors to non-compliance. The shortage of nursing staff meant that healthcare professionals were often overwhelmed with patient care responsibilities, leaving less time for cleaning and disinfection tasks. The high patient acuity in critical care areas added further complexity and urgency to patient care, potentially diverting attention from equipment cleaning and disinfection. To address this, the team proposed shifting cleaning responsibilities from nurses to environmental service personnel, aiming to improve cleanliness and infection control standards.

To assess the effectiveness and feasibility of this proposed change, a pilot study was conducted in the medical intensive care unit (MICU). A pilot study involves implementing a change in a limited, controlled environment to understand its impact before rolling it out more widely. Therefore, education sessions were conducted to prepare the environmental service personnel working in MICU for their new responsibilities. In February 2022, the responsibility for cleaning and disinfecting medical equipment was shifted to the environmental service personnel in the MICU. This represents the first stage of the transition, and it likely involved a period of adjustment as the new responsibilities were integrated into their workflow. In March 2022, the full implementation and takeover by the environmental service personnel took place in the MICU. A monthly audit using fluorescent powder and UV light was conducted in MICU to ensure the cleaning and disinfection process was effective and met the desired standards. The audit results for March and April 2022 showed consistent improvement (figure 1), with a reported 100% success rate under the environmental service personnel. This outcome suggests that the change in responsibility has had a positive impact, with all equipment being effectively cleaned and disinfected, reducing the risk of infections within the MICU. The summary of the 2nd PDCA cycle shown in table 2.

Figure 1. Cleaning and disinfection evaluation of equipment in use compliance rate in the medical intensive care unit (MICU).

Table 2. Pilot program shifting cleaning responsibility to environmental services in MICU.

PDCA cycle	Plan	Do	Check	Act
Cycle 2 (January 2022)	Shift cleaning responsibilities for certain equipment to environmental service personnel to reduce nurse burden.	Conduct a pilot programme in the medical intensive care unit (MICU) and provide targeted training for environmental service staff.	Perform monthly audits using fluorescent powder and UV light to check cleaning quality.	Expand this approach hospital-wide after a successful pilot, observing sustained 100% compliance in the MICU.

3rd PDCA cycle

In May 2022, the MDT made a momentous decision: to roll out the project of transferring the duty of equipment cleaning and disinfection from nurses to environmental service personnel in all critical care areas. In line with this project, an extensive education and training programme was organised for all the environmental service personnel working in critical care areas at SSMC. The training sessions for environmental service personnel were conducted, with structured competency assessment post-training. This training aimed to equip these staff members with the necessary knowledge, skills and understanding of the crucial cleaning and disinfection procedures specific to healthcare settings. It was a pivotal step to ensure that the transition in responsibilities would be smooth and that the new team would be well-prepared to handle this task. The impact of this transition quickly became evident through a remarkable improvement in compliance with the cleaning and disinfection protocols. The compliance rate, which had stood at 72% during the first quarter of 2022, saw a remarkable boost. By the third and fourth quarters of the same year, the compliance rate had reached an impressive 100%. This shift from 72% to 100% signifies that all equipment cleaning and disinfection procedures were being diligently followed by best practices (figure 2). The transition from nurses to specialised environmental service personnel for equipment cleaning has proven to be a sound and beneficial decision for the institution.

Figure 2. Cleaning and disinfection evaluation of equipment in use compliance rate 2022 in CCA.

In January 2023, challenges were identified which affected the cleaning and disinfection compliance rate (78% only). It revolved around several key issues that had a direct impact on the practices: (1) new environmental service personnel were appointed in the critical care area, which introduced an element of unfamiliarity with the requirements. (2) An additional concern was raised by the biomedical engineer; according to the user manuals for some medical equipment, it was essential to disconnect or power down the devices before initiating cleaning and disinfection procedures. This was a vital step to ensure the safety and effectiveness of the process. Disconnecting or turning off medical equipment before cleaning was not within the scope of the responsibilities of the environmental service personnel. In light of these concerns, the environmental service personnel were strictly prohibited from cleaning such medical equipment. This decision was made to ensure that all aspects of patient care, including equipment maintenance, adhered to the highest standards of safety and quality.

Unfortunately, the introduction of these new factors and the necessary restrictions placed on environmental service personnel affected the overall compliance rate (figure 3). The challenges presented by these circumstances highlighted the need for a comprehensive re-evaluation of the procedures and the importance of clear communication and collaboration among the nursing department and support service team. The summary of the 3rd PDCA cycle shown in table 3.

Figure 3. Cleaning and disinfection of equipment technique compliance rate 2023.

Table 3. Hospital-wide rollout of new cleaning protocols following staff training.

PDCA cycle	Plan	Do	Check	Act
Cycle 3 (May 2022)	Train all environmental service personnel for cleaning in critical care areas and establish clearer cleaning protocols.	Implement comprehensive training sessions across all critical care units for cleaning and disinfection procedures.	Conduct quarterly audits across units to assess protocol adherence.	Achieve a 100% compliance rate in critical care areas by the fourth quarter of 2022, reflecting successful adaptation of new protocols.

4th PDCA cycle

The MDT met regularly to assess and enhance the processes. One of the areas identified for improvement was the categorisation of medical equipment based on risk levels to streamline and standardise the cleaning and disinfection procedures. The MDT proposed a system of categorisation that helps staff better understand how to handle different medical equipment. The proposed categories were as follows:

1. High-risk equipment: requires disconnection or powering off before cleaning.

2. Low-risk equipment: can be effectively cleaned without the need for disconnection or powering off.

3. Moderate-risk equipment: typically used briefly on patients, such as ultrasound machines.

Over 3 months, the biomedical engineer conducted a comprehensive categorisation process, meticulously reviewing user manuals for each piece of equipment to ensure well-informed and accurate classification criteria. Subsequently, the SSMC cleaning and disinfection procedures policy was updated to incorporate the equipment classification and clarify the responsibilities of various stakeholders within the facility:

1. Nurses and end users: responsible for cleaning and disinfecting high-risk medical equipment connected to patients.

2. Environmental services personnel: tasked with cleaning and disinfecting low-risk medical equipment connected to patients and moderate-risk medical equipment after patient use.

In the last week of March 2023, SSMC officially approved and disseminated the updated SSMC policy on cleaning and disinfection procedures. Throughout April, a series of educational sessions were held for various teams within the facility, including the nursing staff, environmental service personnel and end users. These sessions aimed to provide comprehensive guidance and training on the nuances of the updated policy, ensuring that staff members understood their roles and responsibilities in maintaining a clean and safe environment.

To ensure the policy’s effective implementation and maintain high cleanliness and infection control standards, the IPC team continued to conduct cleaning and disinfection audits. The updated SSMC policy, which incorporated risk categorisation and thorough education and training, led to a significant improvement in compliance rates. From May to July 2023, the compliance rate for cleaning and disinfecting equipment in critical care areas reached 100% (figure 4).

Figure 4. Cleaning disinfection of equipment in use compliance rate—2023.

However, in August 2023, nursing staff turnover in critical care areas introduced new challenges to the implementation of the updated cleaning and disinfection procedures policy. The compliance rate dropped from 100% in July to 81% in August 2023 (figure 4). Nurses’ compliance rate was the main contributing factor to the decreased hospital-wide compliance rate. Nurses expressed their concerns regarding the lack of a reminder system for identifying the responsible party for cleaning specific medical equipment. The summary of the 4th PDCA cycle shown in table 4.

Table 4. Implementation of risk-based equipment categorisation and role clarification.

PDCA cycle	Plan	Do	Check	Act
Cycle 4 (March 2023)	Introduce risk-based equipment categorisation (high, moderate, low) to streamline and standardise cleaning processes.	Implement categorisation policies with clear cleaning responsibilities based on equipment risk level.	Audit compliance to ensure understanding and application of risk-based cleaning protocols.	Finalise updates to policies and provide additional training to reinforce the categorised approach, observing improved adherence.

5th PDCA cycle

In response to these concerns, the MDT recognised the need for a practical system solution. They proposed introducing a tagging system for medical equipment to serve several crucial purposes:

1. Disinfectant wipe identification: tags would indicate the correct disinfectant wipe for each equipment piece, following user manual recommendations.

2. Equipment categorisation: tags would display the equipment category based on risk classification, simplifying the identification of cleaning responsibilities.

3. User manual access: tags would include QR codes or brief instructions for quick access to user manual guidelines, ensuring proper cleaning procedures are followed.

The tagging system, introduced in October 2023, streamlined and standardised the cleaning process in critical care areas, making it more intuitive for staff. This innovation addressed nursing concerns and reinforced infection control and maintenance, especially with staffing changes. Its implementation led to a compliance rate of over 90% in the last quarter of 2023 and the first quarter of 2024, as shown in figure 5. The summary of the 5th PDCA cycle shown in table 5.

Figure 5. Cleaning and disinfection evaluation of equipment in use compliance rate in CCA. PDCA, Plan Do Check Act.

Table 5. Tagging system introduced to support compliance and clarify cleaning responsibilities.

PDCA cycle	Plan	Do	Check	Act
Cycle 5 (October 2023)	Introduce a tagging system for equipment to clarify cleaning instructions and responsibilities.	Apply tags to equipment, indicating proper disinfectant and risk level, and provide QR codes for user manuals.	Perform compliance audits to verify adherence to tagged cleaning protocols.	Maintain compliance above 90% into early 2024, showing the tagging system’s effectiveness in supporting cleaning standards.

Discussion

The journey towards effective and consistent cleaning and disinfection of medical equipment in critical care areas at SSMC involved strategic initiatives, challenges and innovative solutions. The primary goal was to minimise the occurrence of hospital-onset C. auris within critical care areas and create a safer environment for patients and healthcare professionals by improving compliance rates to over 85%.

The process began with evaluating existing practices and identifying areas of concern. Introducing a risk-based categorisation system for medical equipment and reallocating responsibilities to nurses and environmental service personnel provided a clear framework. Educational sessions and meticulous categorisation by the biomedical engineer ensured staff were prepared for the new policy. Implementing a tagging system for disinfectant type, equipment category and user manual instructions further streamlined processes.

Compliance data showed significant improvement. An MDT approach, with regular meetings and comprehensive training, facilitated an organised cleaning process. Transferring cleaning responsibilities in the MICU to environmental service personnel, coupled with rigorous training and auditing, led to compliance rates peaking at 100%.

However, nursing staff turnover caused compliance rate fluctuations, highlighting the need for solutions to maintain adherence during staffing changes. The tagging system helped address these issues, maintaining rigorous infection control during such periods.

Comparing 2021–2024 statistics, the initiatives significantly improved compliance rates from an average of 60% in 2021 to more than 85% in 2024. SSMC’s proactive and adaptable approach underscores its commitment to high-quality care in a safe environment. Continuous efforts and innovative solutions provide valuable insights into addressing the challenges, maintaining rigorous cleaning and disinfection procedures, ensuring patient safety and reducing C. auris in critical care areas. This significantly improved the rate of hospital-onset C. auris from 1.4 per 1000 patient days in 2021 to 0.5 per 1000 patient days in 2024 (figure 6).

Figure 6. Rate of hospital-onset Candida auris per 1000 patient days.

Limitations

Despite the positive impact of the implemented interventions, several limitations hindered consistent progress. High staff turnover, particularly within the nursing workforce, led to fluctuations in compliance rates and necessitated continuous, resource-intensive training and re-evaluation efforts to maintain standards. This turnover introduced a need for ongoing education that strained resources and led to variability in adherence to protocols.

Additionally, the shift of cleaning responsibilities to environmental service teams led to initial lapses in compliance, stemming from the need for acclimatisation to healthcare-specific standards and procedures. Furthermore, the effects of the COVID-19 pandemic may have indirectly influenced hospital-acquired infection rates, such as C. auris, due to resource reallocation and heightened infection control demands. Despite the successes, several limitations were encountered. Transitioning cleaning duties to environmental service personnel initially dropped compliance due to unfamiliarity with requirements and the need to power down certain equipment.

Staff turnover, especially among nurses, caused fluctuating compliance rates, necessitating continuous training and re-evaluation, straining resources.

Conclusion

The strategic initiatives undertaken at SSMC have markedly improved compliance with infection prevention protocols, especially in cleaning and disinfecting medical equipment. This progress is evident from an increase in compliance rates from 56% in the second quarter of 2021 to over 90% in the first three quarters of 2024. This enhancement has contributed to a significant reduction in hospital-onset infections, such as C. auris, within critical care areas, bringing the rate down to 0.5 per 1000 patient days in 2024, ultimately supporting better patient safety outcomes.

The success of these efforts underscores the importance of a multidisciplinary approach, consistent staff training and the adoption of innovative solutions—such as tagging systems—to tackle challenges posed by staff turnover and fluctuating compliance rates. Continuous evaluation and adaptation of infection control processes are essential to maintaining these high standards. However, sustaining these advancements will require a continued commitment to resources and proactive engagement to adapt to evolving challenges. Allocating sufficient resources and ensuring ongoing commitment will be critical to achieving lasting success in IPC efforts at SSMC.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.