Hygiene in healthcare environments has always been a sensitive affair. Even before the pandemic, healthcare settings have had to maintain the highest levels of hygiene in order to keep their HAIs in check and ensure patient safety. 

The design of a healthcare facility can influence the transmission of healthcare associated infections by air, water and contact with the physical environment.

1. The risks of transmission of infections can be reduced through a number of design features, including having surface finishes (floors, walls, benches, fixtures and fittings) that are easy to maintain and clean; and adequate systems and procedures for waste management, cleaning and linen handling.

2. Healthcare facilities are to be:

• Visibly clean and free from non-essential items and equipment to facilitate effective cleaning
• Well maintained and in a good state of repair
• Routinely cleaned in accordance with a documented routine cleaning schedule.

Documentation of cleaning procedures

Documentation of cleaning procedures is as important as the cleaning procedure itself. This documentation must be available to relevant staff. At a minimum the documentation must include:

• Healthcare facility accountability and reporting lines
• Minimum cleaning and disinfection frequencies and methods, including chemicals used and specific training required by staff
• Safety data sheets of chemical agents used
• Information on correct use of personal protective equipment (PPE)
• Equipment used, maintenance and servicing of equipment and financial asset identification
• Contingency plans, including outbreak management and leave requirements of cleaning staff.

Maintenance issues affecting cleaning

As buildings and fixtures age they become more difficult to clean and maintain in an acceptable condition. Annual preventative maintenance reviews must be conducted to identify problems with existing infrastructure (i.e. buildings and fixtures) that may make it difficult or impossible to meet cleaning standards. These reviews must record those areas that require repair, resurfacing, repainting or recovering. Infrastructure problems that are found to increase the risk of infection (i.e. worn porcelain, lack of storage, thread bare carpet) are to be documented In extreme and high risk areas in particular these problems are to be rectified as soon as practicable.

Cleaning methods

Detergents and disinfectants

Routine cleaning with detergent, suitable for the surface (or item) to be cleaned, and water is recommended for most situations. The use of disinfectants as part of routine cleaning is only recommended for:

• Extreme risk areas
• As part of outbreak management
• Terminal cleaning following a multidrug-resistant organism (MRO)/infectious disease
• Toilets.
• When selecting a cleaning agent (detergent, disinfectant or dual-purpose cleaner/disinfectant) for a cleaning task, the purchasing team/committee is to ensure that:
• The cleaning agent is approved by the concerned local authority.
• The cleaning agent is effective against particular organisms including
  • Microbiological activity and contact time to kill microorganisms.
  • The intended purpose of the product is as per the manufacturer’s instructions.
  • The cleaning agent is suitable for the surface or setting.
  • The facility has the capacity to comply with the manufacturer’s instructions.
  • The cleaning agent has the appropriate environmental sustainability credentials.
  • The cleaning agent’s safety data sheet is available and accessible for cleaning staff.
  • The facility has the capacity to ensure that cleaning staff have access to the relevant cleaning equipment and PPE to be used with the cleaning agent.

Cleaning equipment

There have to be properly documented procedures for effective use, maintenance and storage of cleaning equipment such as mops, cloths and solutions.

Reusable cleaning equipment must be maintained, used, cleaned/laundered and stored in accordance with their manufacturer’s instructions and national and international standards. 

• After use, single-use cleaning equipment is to be disposed of in accordance with their manufacturer’s instructions.
• Ward and unit staff must have access to cleaning equipment during times when regular cleaning staff are not available.
• Before commencing a cleaning task, staff must check that the selected equipment is in good working order and appropriate for the cleaning task as per the manufacturer’s instructions and facility requirements.
• On completion of the task, reusable cleaning equipment must be cleaned and, if required, disinfected, laundered and stored as per the manufacturer’s instructions and relevant national and international standards.
• Disposable or single-use cleaning equipment must be disposed of in the correct waste stream and as per the manufacturer’s instructions.

Colour coding cleaning equipment

Identification through colour coding of reusable cleaning equipment utilised in the different areas of a health organisation is recommended as the most effective method for infection prevention. 

Cleaning blood and other body substance spills

Stringent protocols to ensure that spots and spills of blood and other body substances are cleaned as soon as practicable to reduce contamination:

• Small spills (up to 10 cm) can be wiped up with absorbent material (e.g. paper towels) and cleaned immediately or as soon as practical.
• Larger spills must be first contained and confined with absorbent material, followed by removal of any broken glass or sharp material as required, and then cleaned as soon as practical.
• The use of disinfectants in the cleaning of blood or other body substances is to be based on an assessment of risk of transmission of infectious agents from the spill, which should be done in consultation with local infection prevention and control staff.

Identifying risks

Each healthcare facility must use a risk management framework to determine individual and collective risk(s) and inform management options and priorities to reduce the risk of HAIs.

High-touch vs low-touch surfaces

Any surface may become contaminated, and the risk of contamination is greater for surfaces and items that are touched or handled more frequently.

High-touch surfaces are those that are frequently touched by staff, patients and/or visitors. In areas where clinical care occurs, high-touch surfaces require more frequent cleaning than low-touch surfaces.

Surfaces and items in proximity to patients that are more vulnerable to infection require more frequent cleaning. More heavily contaminated surfaces require more frequent cleaning than less contaminated items.

Functional areas

A functional area refers to any area in a healthcare facility that requires cleaning. The functional areas have been grouped under four risk categories: extreme, high, medium and low. These risk categories reflect the frequency and intensity of cleaning required to meet minimum cleaning outcomes.

Each facility must determine the frequency and intensity of cleaning each functional area that is required to meet the cleaning standards. It is recommended that high and medium risk functional areas start with a daily clean, then intensity and capacity are increased according to risk assessment of the patient, procedure type and frequency and possible risk of MRO/communicable disease transmission.

All rooms and corridors with direct open access into a designated functional area require cleaning to the same level of cleaning as the functional area. Bathroom and toilet cleaning frequency should be appropriate for the number of people using them.

Extreme risk areas

Extreme risk areas are areas with the greatest risk of transmission of infection, as patients in these areas are very susceptible to infection (i.e. are immune-compromised and/or have significant comorbidities) and/or are undergoing highly invasive procedures. Cleaning outcomes must be achieved through the highest level of cleaning intensity and frequency.

High risk areas

High risk areas are areas where infection transmission risk is high because patients are susceptible to infection and invasive procedures are conducted here. Cleaning outcomes must be maintained by a frequent cleaning schedule with capacity for rapid spot cleaning.

Medium risk areas

Medium risk areas are areas where there is a medium risk of infection. Cleaning outcomes must be maintained through scheduled regular cleaning with capacity for spot cleaning.

Low risk areas

Low risk areas are areas where the risk of infection is low as there are no invasive procedures performed. Cleaning outcomes must be maintained through scheduled regular cleaning with capacity for spot cleaning.

Cleaning audits - Internal and external

All healthcare facilities must have a cleaning audit system that measures and records cleaning outcomes. Internal cleaning audits must be performed in all functional areas across all risk categories.

The staff member undertaking internal cleaning audits must be trained in undertaking cleaning audits and have a thorough knowledge of both the cleaning standards and cleaning processes. During the cleaning audit the cleaning auditor is to be accompanied by a staff member of the area being assessed to ensure issues are identified, ratified and validated by the area.

The cleaning auditor is to provide feedback to individual areas along with a plan to rectify any highlighted problems. Results of cleaning audits, together with quality improvement plans and outcomes, are to be documented and tabled at the PHO’s quality and risk committee, infection prevention and control committee and other relevant committees.

The cleaning auditor is to always refer to the previous cleaning audit to understand what sections were audited, identify any previous actions and to know what sections are required to be audited.

At a minimum, cleaning of all extreme and high risk functional areas of a healthcare facility must be externally audited every two years. These external cleaning audits are to include review and validation of the internal cleaning audit program; all the cleaning audit results; variance results; action plans and policies related to cleaning and cleaning Audits.

External cleaning audits are to be conducted by cleaning auditors who are trained in undertaking cleaning audits and have a thorough knowledge of both cleaning standards and cleaning processes