COVID-19 has turned the world in ways that was unimaginable before the first quarter of 2020.

This pandemic has changed the way we behave, interact, socialize, travel and even greet each other. For example, a young mother who returns from grocery shopping now scrubs her hands as diligently as a surgeon before touching her child. The sound of a mere cough or sneeze in a mall makes people turn around in abject horror. This virus has changed our lives, and there seems to be no accurate prediction on when the world will return to the pre-covid normalcy levels.

During these trying times, infection control is even more sensitive in healthcare facilities. How do hospitals prevent infections and safeguard their patients, staff and visitors?
We spoke to some experienced healthcare professionals from UAE and Kuwait to gain their perspective. 

Dr Neesha Nair and Shaheena Surani, Medcare Hospital

Infection control protocols and processes 

Infectious germs are infamous and it is very vital that hospitals have an upper hand in controlling them. At Medcare a comprehensive approach to the patient, employee, and visitor safety has been adopted which focuses aggressively on Infection Prevention and Control (IPC) measures. It’s not always the expensive resources that are effective for infection control. What is vital is a strategic approach, clinical leadership, and willingness of the team to ensure safe practices are embedded in the system. We have invested our energies in developing the core components which includes a robust IPC program based on evidence-based guidelines, strengthening our laboratory capacity, education and training, surveillance, monitoring and feedback on IPC practices, workload, staffing and environment. 

With multimodal strategies, we have been successful in controlling the spread of infections even during high occupancy. Our multidisciplinary team is well versed with the latest protocols. We have also implemented an emergency response plan to handle existing and emerging infections. Appropriate planning tools are being used to visualize and estimate the necessary resources required. The entire workforce has been trained for the recommended infection control practices and social distancing methods. 

In addition to the clinical management, Medcare Hospital has a robust environmental cleaning policy, all housekeeping staff are trained for cleaning and decontamination procedures. We are well equipped with the recommended personal protective equipment’s, cleaning and disinfectant agents required during this era. To provide high-quality care to our patients and promote safety among the staff the hospital has also implemented changes in the air and ventilation system by building more negative pressure single rooms and conversion of existing air handling system to prevent air contamination and cross-transmission. 

All efforts are being done to have principles of infection control throughout the continuum of care. Medcare has also initiated telemedicine, drug delivery, and home care services to ensure patient safety and business continuity. 

Changes in the past 2 years

The past 2 years gave us an opportunity to assess the effect of multimodal IPC bundles and strategies. Previously, strategies such as universal masking, visitor restrictions isolation precautions, and deep environmental cleaning were only deployed in high-risk units. But now we have enhanced hospital-wide IPC measures. These were implemented following a thorough risk assessment with the goal of mitigating possible risks connected with human, financial, technological, and operational aspects. Medcare Hospital has also re-examined its physical environments and infrastructures to promote social distancing and avoid any potential surge and risk of transmission. An evidenced-based supply chain model has been also implemented to boost the inventories and to maintain the safety stocks for the critical infection control supplies. Newer technology for cleaning and disinfection are also being considered to maintain hygienic conditions free from a pathogen. While the various initiatives undertaken as part of the infection control and prevention program assisted us in maintaining control, the aftermath provided an opportunity for newer learnings which Medcare continues to follow and adopt as part of the NEW normal in its daily operations. 

Overcoming challenges

We could overcome the challenges, thanks to our passionate and dedicated team. There has been an increase in data reporting requirements, so we geared up having power BI to help generate dashboards, we automated capturing newer patient information using JOT. Workloads have been a major stressor and we supported our teams by providing all possible psychological PPE. With restrictions on classroom sessions and protocols on social distancing, we could realize utilization of communication technology is an easy and affordable way to disseminate knowledge on ICP and we could roll out multiple learning sessions, call on everyone together to brief them on the latest guidelines. One of our greatest success was our training for the support services across Medcare hospitals and medical centres where we had 100% attendees logging in through Zoom. There have been some other minor challenges but in the end, all these experiences have made us better equipped and wiser.

Brian de Francesca, Chief Operating Officer, Kuwait Hospital

The most dangerous place

Hospitals are dangerous places. While there is a one in million chance of experiencing an adverse advent on a commercial air flight, there is a one in three hundred chance of being harmed in a hospital.  Most of these hospital “problems” will have little to do with your doctor.  For the most part, the doctors and nurses do a fine job. There is a greater likelihood of having an adverse event that is related to an unclean hospital, than a medical error.  Yet for the most part, “housekeeping” staff are given very little managerial time and attention.   “The cleaning people” are a minor, but necessary, afterthought.   And this is a huge mistake.

Secret weapon 

I am often asked about how I continually develop and manage award winning hospitals.  While many executives are obsessed with creating chrome and marble clad icons that are overly stuffed with mega magnet MRIs and fancy robotics of questionable utility, I focus on the sometimes-invisible things that truly matter – like, keeping the place clean.  There is significant evidence showing a correlation between how clean a hospital is, and the quality of care and outcomes that a patient experiences.   Based on over 3 decades of my international healthcare experience, I have learned that while it is important to do the right things, it is equally important to avoid the wrong things – like allowing your patients to get sick or worse from avoidable infections.   Many hospitals are not as clean as you think they are, but you may not see it. In fact, you probably cannot see the “dirtiness” without a microscope – but it may still be there.  The saying goes, “out of sight, out of mind.” Hospital hygiene does not appear to be at the front of mind for most executives.

Throw bodies at it

Most hospitals see “housekeeping” as necessary, but of far lesser importance than the deified medical team, or the shiny mountain medical equipment both of which consume more money and management time than keeping the hospital clean.  When it comes to hiring the “cleaning people,” many hospital executives tend to pay the “lowest price per body.”   This “lowest cost per unit” mentality results in high risk for patients.  Many of the housekeepers I have met in hospitals are inexperienced, untrained, extremely low paid, many times sick (with TB and other diseases), older, frail and timid. They are certainly not engaged, knowledgeable and empowered team members who embrace the knowing that they are responsible for ensuring that the facility does not become a biohazard, putting patients, visitors, and staff at risk – especially in these times of COVID-19. Having a clean and safe hospital is not achieved through high body count.

A sick hospital

Many years ago, I was a new executive at prominent publicly listed private hospital.  It was considered “one of the best.” The hospital had an army of cleaners – most were slowly, almost invisibly, wandering the corridors pushing a dark grey mop; heads down, listless. I thought of Zombies. My concern was that our hospital acquired infection (HAI) rate was higher than international averages.  At times, I could feel the crush and crumble of dirt under my feet as I walked the hospital – though I could not “see” it. The place did not “feel” clean, the workers did not look engaged, and our infection rate provided some “evidence” that there was a problem.   The place was sick. I expressed my concern to our manager in charge of housekeeping services and our housekeeping subcontractor as well. They replied that we have a very large team, working 24-hours a day and that they work at many other hospitals as well. But our place was still sick. I asked how they knew it was truly clean, and they replied that it was clean because we had a lot of people cleaning it. But the place was still sick. I asked how we measured cleanliness, and was told, that we do not, because we cannot. I was told that since “you cannot quantify cleanliness” they hire as many low-cost people as the budget allows, to go through the motions of moping and wiping.   And infection rates rose, our hospital remained sick.

There is safety in numbers

I did not accept this inability to quantify cleanliness, so I did some research and found there were many ways to put a number on cleanliness.  Cleanliness can be detected to 0.01 grams per square centimeter levels using a variety of methods such as visual inspection, low power microscope inspection, wiping and visual inspecting, water break tests, atomizer tests, nonvolatile residue inspection, surface UV Fluorescence detection, tape test. Finer levels of cleanliness (between 0.01 – 0.001 grams per square centimeter) can be achieved through Millipore filter measurement techniques such as optical microscopy, extraction, oil evaporation, oil soluble Fluorescence, gravimetric analysis, surface energy tests, contact angle measurement, particle counting. So, you can in fact “quantify cleanliness.”   

One of my favorite and useful quotes from an old dead man is this one from Lord Kelvin: “When you can measure what you are speaking about, and express it in numbers, you know something about it. When you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarely, in your thoughts advanced to the stage of science.” And now that my knowledge of cleanliness was improving – I wanted to put it to good use; to reduce our hospital acquired infection numbers.   

Pay for performance

Historically, we contracted with a housekeeping company based on a tendering basis; whichever company gave us the “most bodies and the lowest total cost” – got the contract.   It was a body-rental contract.   I turned that on its head.  I issued a performance-based RFP.   We would pay a company based on keeping the hospital clean to certain (measurable) level; if the dirtiness exceeded this level, there would be financial penalties.   Different areas of the hospital, demanded different levels of “maximum dirtiness.”   And the number of bodies did not matter – it was up to them to use 1 or 100 bodies – they just had to keep the place clean.

Few companies were up for the challenge, but one was.   The result was that the head count of the housekeeping personnel dropped 26%, the amount we spent for housekeeping services decreased by 15% and the contractor was able to meet our “quantified” cleanliness target (different areas had differing levels of maximum dirtiness). Over the coming months our hospital acquired infection rate decreased to the low side of internationally acceptable levels – mission accomplished – a cleaner, safer and more efficient hospital.

I don’t wear a tie

From there, I became more knowledgeable about the significant importance of hospital hygiene, which resulted in me no longer wearing a necktie.   I am often asked why I choose not to wear a necktie to work – since a fine cravat is part of the uniform of most mature and successful healthcare executives.  I do not wear a tie because research has shown that neck ties are likely carriers of infection-causing bacteria. Specifically, a 2004 study at Queens Hospital found that 47 percent of the ties worn by medical staff at the hospital harbored illness causing bacteria.  I do not wear a tie because they may harbor nasty bugs; and also so that I have the opportunity to talk about the many hidden dangers around us.  What may be most important at a hospital, may not be the fancy chrome and marble that you can see; but the germs and bacteria that you cannot.

Arjun Mohan, Group CEO, Al Ataa Group, UAE

A hospital is a place where one steps in with lot of skepticism and care nowadays. Smaller ailments are not taken to doctors as before, and the hospitals take immense care in trying to keep themselves sterile and infection free. In countries such as UAE, the regulators are constantly vigilant and enforce hygiene and cleaning standards with extreme diligence. This has necessitated that cleaning companies need to adapt the way they work in healthcare facilities.

Best practices

The human factor in cleaning is so important that a single untrained or negligent cleaner caninfect hundreds of patients or co-workers. Constant infection control related training is a must.

Such trainings should focus on raising the awareness of potential risks and ways to mitigate them. Further, due vaccinations and frequent testing for infections should be enforced so that the very crew that should prevent infections spread it. Appropriate usage of PPEs and their due disposal are also necessary to mitigate infections risks.

Waste management is an especially hazardous aspect of cleaning a hospital. Housekeeping staff are prone to exposure to various pathogens in Operation Theatres, LDRs, ICUs and waste collection areas. The crew must be trained appropriately on site in various related aspects such as waste segregation and bagging, needle pricks, cleaning of spillages of body fluids, due precautions in collection and management of medical waste, etc. Such periodical trainings should be imparted jointly by the cleaning company and the infection control department of the hospital.

Secondly, the chemicals used in cleaning and sanitizing hospitals should be approved by the relevant health regulator, as well as the infection control department of the hospital. The dilution ratios should be followed accurately, and their application should be as per the manufacturer’s instructions. Gone are the days when all-purpose cleaning chemicals and bleach were the only necessities in a cleaning company’s arsenal. To combat such a virulent virus, the cleaning techniques must be perfected to deploy the correct chemicals for the appropriate areas, at the right dilutions. The use of automated chemical dispensers is a good practice to ensure correct dilution ratios.

Automation

Automation is another area that cleaning companies must focus on. As the reliance shifts from large numbers of cleaners to a dedicated and skilled crew of housekeeping staff armed with automated tools, this improves the quality of cleaning and sanitization in hospitals. An automated scrubber drier, with its brushes rotating at 200 RPM, does a much more thorough job at sanitizing a surface than a bunch of cleaners with mops. Further, the age of autonomous cleaning bots has already arrived.

These independent machines can go in, navigate around obstacles, clean, disinfect and even clean themselves. Such automation can reduce the chance of housekeeping staff getting infected, as well as improve the standard of sterilization effected. Automated scrubbers, ozone generators, UV disinfectant bots are all examples of such technology that are available and suitable for deployment in healthcare facilities. We might not see the cleaners getting replaced by an army of robots in the near future, yet these machines are becoming more accessible and economical, and thus the cleaning companies should evaluate their efficacies in deployment, especially in infection prone areas.

Specialization

As in many parts of the Western World, it would be prudent for some facility management companies to adapt and specialize in managing cleaning services at hospitals. This will give rise to dedicated players having staff and management who are adept and experienced in managing the numerous technical and operational challenges of cleaning hospitals. This will also enable the healthcare operators to have access to specialized cleaning crews who are able to operate with minimal supervision on ground.

The pandemic has changed the way soft services operate, and we shall see more changes that will improve efficacy and optimal resource utilization, as the market will demand it and this will give rise to a new batch of cleaning companies who specialize in the healthcare industry.