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.
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.
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 3 534 439 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 1 267 134 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).
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.
National Health and Medical Research Council (Australia).
Description of intervention(s) / exposure
Implementation of a cleaning bundle intervention, consisting of 5 interdependent components (training, audit, communication, product and technique), in 11 hospitals for randomly allocated time periods between 20 weeks and 50 weeks.
Interdependent bundle components are each tailored to meet the site context.
The study team will deliver tailored training activities (reflecting the educational needs identified at each site during the control period through the environmental services pre- intervention surveys):
- at the commencement of the intervention phase for all environmental services staff with a role in environmental cleaning
- as part of induction for new environmental services staff with a role in environmental cleaning
- and as required throughout the intervention phase.
Content of the introductory training activity (1-2 hour face-face session for environmental services staff) in week 1 of the intervention period will minimally include: the bundle components, clearly defined roles and responsibilities for environmental cleaning at the site and the impact of environmental cleaning on HAI.
Additional training sessions will continue throughout the intervention period as required by the site and provide responsive feedback from the bundle audit activities. Training will articulate with existing education events and timings in trial sites as much as possible, including induction for environmental services staff, team meetings and annual training updates.
All environmental services staff at each site will follow an established cleaning technique throughout the intervention period when completing a daily clean or discharge clean.
It will be communicated to environmental services staff through the training and through availability of posters, fact sheets and tip sheets/ cards (e.g on the cleaning trolley).
Each trial site will have existing supply arrangements for environmental cleaning product, including cleaning equipment. To promote cost-effectiveness and ensure feasibility the product component will be clarified with each site to ensure the product component:
- minimally includes the use of disinfectant for all discharge cleans and for daily cleans of high risk/contact precaution rooms. To ensure organic matter is removed effectively either a 2 in 1 detergent and disinfectant product or a 2-step process will be used
- minimally includes the use of point of care wipes for medical equipment
- is Therapeutic Good Administration approved for that use and setting
- adheres to manufacturers’ instructions for use
- is compatible with other product or application materials (e.g. microfiber cloths) in use
- ensures effective cleaning technique is used.
All environmental services staff with a role in environmental cleaning at the trial site will use this product component throughout the intervention period.
In this cleaning bundle the DAZO fluorescent marker system will be used monthly in the control and intervention periods as an audit tool by the study team or trained members of the site team at each trial site. DAZO® Fluorescent Marking Gel and UV Light system dries on surfaces following application and resists dry abrasion, but is removed with standard cleaning. The locations of the gel dots will be consistent with the Centers for Disease Prevention and Control Environmental Cleaning Checklist in two different bed and bathroom areas in the Intensive Care Unit and in at least 50% of the hospital trial site wards.
In 3 hospital sites the study team will use ATP luminometry bi-monthly in the same ward sites as the fluorescent markers to audit bio burden of the frequent touch surfaces post daily or discharge clean. The 3 hospitals will be located in either South East Queensland or at an investigator affiliated site due to equipment limitations.
The communication component of the bundle will be implemented by the study and site teams, throughout the intervention period. Communication activities will focus on:
- maintaining a positive feedback loop to all staff about the audit results
- the role of the multidisciplinary team in preventing HAI
- creation of a ‘culture of hygiene’ through hospital wide promotional activities to raise the profile and importance of cleaning in reducing infections and support a culture shift in the perception of environmental services staff
- daily contact between cleaning staff and ward leaders or managers
- supporting the participation of cleaning staff on relevant clinical governance committees.
Site adherence with the bundle components will be monitored by the study team through fortnightly site contact and the review of audit results.
Intervention code 
Comparator / control treatment
The study design is a stepped wedge: each hospital acts as its own control for 8 weeks prior to commencing the intervention.