U.S. hospitals are evaluated on their ability to reduce the incidence of infections patients acquire during their stays, but there's surprisingly little evidence suggesting the best method to disinfect surfaces in patient rooms.
An abundance of research looks at the number of bacteria on a surface before and after cleaning and disinfecting. But few studies have taken the next step to specifically evaluate to what degree those procedures led to fewer patients getting sick. Even fewer studies compared the effectiveness of one environmental cleaning method over another, according to an analysis published Aug. 10 in the Annals of Internal Medicine.
“There is a paucity of studies that can guide the actions of physicians and hospitals,” said Dr. Craig Umscheid, director of the center for evidence based medicine at the University of Pennsylvania's Perelman School of Medicine. The ideal study would be to randomize the selection of different approaches, compare the findings and then look at patient-centered outcomes, such as colonization and infection rates. “It's doable,” he said. “But we found very few.”
Rates of all hospital-acquired conditions dropped 17% between 2010 and 2013, but infection rates remain problematic. An estimated 722,000 patients get an infection while being treated in U.S acute care hospitals, and 75,000 with the conditions die. Strides have been made with certain processes, such as encouraging hand-washing and following the protocols to prevent central-line and catheter-associated bloodstream infections, where much more emphasis has been placed.
However, University of Pennsylvania and ECRI Institute researchers in the recent study looked at 80 studies published internationally between 1998 and 2014, most of which focused on cleaning and disinfecting hard surfaces in intensive care units, such as bed rails, tray tables and call buttons. The pathogens most commonly evaluated on those surfaces were drug-resistant superbugs like MRSA, VRE and C.difficile. The study was funded by the Agency for Healthcare Research and Quality.
Only five of the studies were randomized controlled trials, considered to be the highest quality research. Forty-nine studies focused on the before and after of cleaning or disinfecting, 14 on monitoring of cleaning and disinfection procedures and 17 on implementation of cleaning or monitoring strategies.
The researchers also found very little data on emerging technologies like surfaces made out of metals that are toxic to microorganisms and germ-zapping UV radiation. None of the studies compared the effectiveness of such equipment. “It's really tough to make comparisons,” Umscheid said.
Unlike near-universal acceptance of the importance of hand-hygiene, the role of inanimate objects in the healthcare environment “has swung back and forth like a pendulum,” Dr. Tara Palmore and Dr. David Henderson of the National Institutes of Health Clinical Center wrote in an accompanying editorial.
Palmore and Henderson cited several challenges, including the difficulty of designing studies to evaluate the link given the moving parts and complexity of hospitals, as well as lack of assurance that environmental cleaning procedures are followed consistently. Multicenter, carefully designed and well-controlled studies are needed to help fill the gap, they said.
“Such studies would provide the scientific basis for the design and development of interventions that would increase patient safety in the healthcare environment for decades to come.”