An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial

Mitchell, Brett G., Hall, Lisa, White, Nicole, Barnett, Adrian G., Halton, Kate, Paterson, David L., Riley, Thomas V., Gardner, Anne, Page, Katie, Farrington, Alison, Gericke, Christian A., and Graves, Nicholas (2019) An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial. Lancet Infectious Diseases, 19 (4). pp. 410-418.

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Background: The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals.

Methods: The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureus bacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505.

Findings: Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3534439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureus bacteraemia, and 278 C difficile infections, for 1267134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0.35 to 0.22 per 10 000 occupied bed-days (relative risk 0.63, 95% CI 0.41-0.97, p = 0.0340). The incidences of S aureus bacteraemia (0.97 to 0.80 per 10 000 occupied bed-days; 0.82, 0.60-1.12, p = 0.2180) and C difficile infections (2.34 to 2.52 per 10 000 occupied bed-days; 1.07, 0.88-1.30, p = 0.4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2.07, 1.83-2.34, p< 0.0001) and bedrooms from 64% to 86% (1.87, 1.68-2.09, p< 0.0001).

Interpretation: The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice.

Item ID: 58035
Item Type: Article (Research - C1)
ISSN: 1474-4457
Copyright Information: © 2019 Elsevier Ltd. All rights reserved.
Funders: National Health and Medical Research Council (NHMRC), Kimberly-Clark Professional, Ecolab Pty Ltd, Whiteley Corporation
Projects and Grants: NHMRC 2014–17 Partnership Project (GNT1076006)
Date Deposited: 17 Apr 2019 09:20
FoR Codes: 42 HEALTH SCIENCES > 4203 Health services and systems > 420308 Health informatics and information systems @ 50%
42 HEALTH SCIENCES > 4203 Health services and systems > 420309 Health management @ 50%
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