Aim of the study

The aim of this study was to assess the current status of the routine cleaning of the environmental surfaces at the intensive care unit of the Neurosurgery Department in Alexandria Main University Hospital, Egypt, and to evaluate the impact of enhanced cleaning of the environmental surfaces on bacterial contamination in the same setting.

Study design and setting

A pre- and post-interventional design was conducted in this study at the intensive care unit of the neurosurgery department at Alexandria University Main Hospital, Egypt (room A with eight beds and room B with six beds). The two rooms were having the routine cleaning once every day in the morning at 10 a.m. The present study was conducted between September 2020 and February 2021.

The ICU in this study was receiving about 25 patients per month. It is primarily serves adult patients who have undergone neurosurgery. Common cases include intracranial hemorrhage, brain tumors, and brain abscesses. Some patients with brain stem compression may experience weak gag reflexes, leading to aspiration pneumonia or the need for mechanical ventilation. Central lines are frequently inserted in these patients. Common ICU-acquired infections include ventilator-associated pneumonia, central line infections, and surgical site infections. While the average length of stay in the ICU is typically 3 to 7 days, which may not be enough to cause the ICU-acquired infections, some patients may require prolonged care for up to 30 days or more. The American Society of Anesthesiologists (ASA) score for patients in this ICU generally ranges from 2 to 5, indicating varying degrees of health status and surgical risk. So, it is of great importance to apply an effective environmental cleaning technique.

Target population and materials

All healthcare cleaning workers and nurses were recruited for the study. Ten workers and eight nurses are responsible for each ICU room. Samples were taken from ICU environmental surfaces: from the high-touch areas around each bed (side tables, suction machines, medical devices, headboard of the bed, side rails, footboard, light switch, etc.), doorknobs, and nurse counters. The materials used in the hospital-built environment, particularly in the ICU, while durable, such as stainless steel, marble, and ceramic, are not entirely new, and some have cracks or broken that could harbor bacteria if not properly cleaned and disinfected. Sinks are located outside the ICU. These factors emphasize the importance of rigorous cleaning and disinfection practices to prevent the spread of infections. Hospital records were used to extract the HAI rates in the ICU units before and after the intervention.

Sampling design

For the healthcare cleaning and disinfection team, half of the healthcare cleaning workers and nurses (those who were responsible for room A cleaning) were included in the application of the enhanced cleaning technique of the intervention phase (eighteen persons), and the other half, who were responsible for room B cleaning, did not receive any new instructions about cleaning (except after the end of the research for ethical consideration). For environmental sampling, 736 environmental surface swabs were taken (416 samples from room A and 320 from room B) (Table 1) through convenient sample techniques. Three samples from the area around each bed before and after cleaning were taken. Besides, one swab from the nursing counter and another one from the doorknob were taken. This process was repeated twice per week for 4 weeks.

Table 1 Distribution of samples taken from ICU roomsData collection method and toolsPredesigned interview questionnaire (supplementary file I)

The questionnaire consisted of two parts. The first part was concerned with the socio-demographic data (sex, age, education, occupation, marital status). The second part assessed the participants’ knowledge of the significance of hand hygiene and the appropriate times for hand-washing. Additionally, we assessed their understanding of standard and transmission-based precautions. Also, we asked about cleaning technique in details. The questionnaire includes items about frequency and schedules of cleaning, cleaning methods, direction of cleaning, disinfectant used and its concentration, materials and equipment used (including cleaning cloths, dust mops, disinfectants, and scrubbers), how to clean the equipment after finishing the cleaning process, and the proper technique to clean human spills. Previous training about cleaning and disinfection, the presence of supervision during cleaning, and the purpose of the cleaning and disinfection of healthcare facilities were also asked.

The questionnaire was obtained from previously validated research questionnaires [20,21,22]. Two professors (in public health and infection prevention and control) revised the questionnaire to check the content validity and recommended a few modifications, which included replacing and adjusting some questions. The English questionnaire was translated into Arabic by two separate native speakers who are specialists in public health.

A ‘1’ point was given for the right response, while a ‘0’ point was given for the wrong response. For the multiple correct answer questions, complete correct answer received ‘2’ points, incomplete correct answer took‘1’ point and incorrect answer received ‘0’ point. After adding together all of the scores, a percentage between 0 and 100% was calculated. Three categories have been established for the knowledge and practice level assessment: low (0 ≤ 50%), fair (50 ≤ 70%), and good (70–100%).

Observational checklist

An observational checklist obtained from the Centers for Disease Control and Prevention (CDC) [23] (Supplementary File II) was used to assess the practice of the healthcare cleaning workers and nurses and to evaluate the level of cleaning visually. There is a list of the items that are present in the patient’s room that are considered high-touch surfaces. The checklist was based on categorizing the objects by three parameters: cleaned, not cleaned, or not present in the room. The rule of this categorization is whether the surface has dust or spills on it. This assessment was done visually immediately after the cleaning process. The visually clean item took ‘1’ point and the unclean one received ‘0’ point and the percentage of cleaned and dirty items was calculated.

Data collected from the records

The rates of HAI occurring in the ICU of the neurosurgery department 6 months before and after the application of the enhanced cleaning intervention were obtained from the IPC records.

Environmental samples

Swabs from environmental surfaces were collected using a steel template (25 cm2 sample area) as guided by the CDC [24]. Swabs were taken from the high-touch areas in the two intensive care rooms A and B (3 swabs from the high-touch areas around each bed, 1 swab from the counter, and 1 swab from the doorknob) before and after cleaning and repeated two times per week for four weeks. The intervention was applied in room A, as it contains a higher number of beds than room B (8 beds vs. 6 beds). The samples from the two rooms were matched to be taken at the same time on the same days.

The collected swabs were immediately transported to the lab and cultured on nutrient-agar plate media. The samples were incubated at 37° C for 48 h, and the total aerobic colony count (TACC) was counted using a colony counter. The microbiological cut-off level for environmental surface contamination was set at 5 CFU per cm2. Colonies from the cultured plates were taken randomly to carry out Gram staining to detect Gram-negative and Gram-positive bacteria [12, 25].

Pilot study

A pilot study was carried out before the implementation of the actual study to assess the status of the routine cleaning of the environmental surfaces in the high-touch areas in the two intensive care rooms A and B (3 swabs from high-touch areas around each bed, 1 swab from the counter, and 1 swab from doorknob), for a total of 184 swabs. Also, it was conducted to determine the practicability of the tool used (environmental swabs) and identify obstacles that could be faced during the implementation of the study. It helped in identifying the preferred time and locations to collect the samples. It entailed taking samples from high-touch areas in the study setting before and after routine cleaning. The geometric means of all the samples before and after cleaning were above the allowable limit in all samples (above 5 CFU/cm2), indicating the urgent need for intervention.

Educational program about enhanced cleaning

When observing the routine cleaning and after data extraction from the questionnaire we found inconsistent cleaning procedures, including the absence of regular detergent use prior to disinfection, improper disinfectant concentration and handling, the directions of cleaning were haphazard, the cleaning mop did not exchange frequently, improper cleaning of the equipment after finishing the cleaning process, and absence of supervision during cleaning (routine cleaning).

To improve cleaning procedures in the ICU, we developed an educational program for healthcare cleaning workers and nurses responsible for cleaning and disinfecting Room A. The program consisted of three interactive sessions held within a month, each lasting 30–45 min. The training used audio-visual presentations and group discussions to emphasize the importance of enhanced cleaning and its key components. Enhanced cleaning consisted of a two-step process to effectively clean and disinfect surfaces and equipment. Initially, surfaces were cleaned with detergent to remove visible dirt and debris, creating an optimal environment for subsequent disinfection. The second step involved applying a suitable disinfectant at the correct concentration for the required contact time to eliminate microorganisms. The program educated the participants about the enhanced cleaning by covering the following points [22, 26]:

Hand hygiene: The educational program emphasized the critical role of hand hygiene in preventing the spread of infections. Participants were instructed on the proper technique for hand washing, including using soap and water for at least 20 s, drying hands thoroughly, and using hand sanitizer when soap and water are not available. Key moments for hand hygiene were highlighted, such as before and after patient contact, before and after a clean procedure, and after using the bathroom. Additionally, the program addressed the importance of wearing gloves and disposing of them properly to prevent cross-contamination.

Standard and transmission-based precautions to minimize the risk of infection transmission. Participants were instructed on the importance of wearing appropriate personal protective equipment (PPE), such as gloves, gowns, masks, and eye protection, depending on the situation. The program also covered the proper handling and disposal of contaminated materials, including soiled linens, medical waste, and bodily fluids. Additionally, participants were educated on respiratory hygiene practices, such as covering coughs and sneezes with a tissue or elbow, and maintaining a safe distance from others.

Dedicated Supplies: We trained staff on the importance of using cleaning supplies designated specifically for the ICU and not shared with other areas. This included fresh mops and buckets with fresh cleaning solution for each cleaning session.

Proper Cleaning Techniques: The program emphasized the importance of regularly changing cleaning cloths during disinfection and never reusing the same cloth in disinfectant solutions (avoiding “double-dipping”).

Cleaning Frequency: Staff learned about the recommended cleaning schedule: disinfecting high-touch surfaces twice daily at a minimum, and more often as needed. Additionally, they were trained to change cleaning cloths between cleaning different patient zones within the room.

Disinfectant Preparation and Use: The training covered the proper preparation of chlorine-based disinfectants, aiming for a concentration of 500–5000 parts per million (ppm) of free chlorine (which can be achieved by diluting 5% chlorine bleach at a ratio of 1:100 or 1:10). Staff also learned about the crucial “contact time” - ensuring the disinfectant remains wet on surfaces for at least 10 min to be sure of killing or inactivating serious microorganisms such as Mycobacterium tuberculosis, hepatitis B virus, or human immunodeficiency virus, especially in areas with high risk of infection like the ICU particularly in limited resources facilities.

Blood and Body Fluid Spills: The program covered the proper response to blood and body fluid spills. This included immediate removal of spills using a special disinfectant designed for such situations (intermediate-level disinfectant). We also stressed avoiding the use of combination detergent-disinfectant products for spills.

Evaluation of the interventional program

To assess the effectiveness of the training program, environmental samples from high-touch areas in the ICU room before and after the intervention were collected. These samples were analyzed to measure TACC and stained by Gram staining to calculate the percentage of Gram-positive and Gram-negative colonies.

Ethical considerations

The researcher sought the approval of the Ethics Committee of the High Institute of Public Health at Alexandria University, Egypt, for conducting the research. The researcher complied with the International Guidelines for Research Ethics. Informed consent was obtained from all study participants after an explanation of the purpose and benefits of the research. Anonymity and confidentiality were assured and maintained. The non-intervention group was educated after the end of the study. The clinical trial registration number is PACTR202402531001186.

Statistical analysis

All the data collected from the questionnaire, records, and microbiological samples were entered into an Excel sheet. The collected data was subjected to statistical analysis using the Statistical Package for Social Science (SPSS) software package version 20.0. The median and interquartile range (IQR) were calculated for the knowledge score. Quantitative data on the bacterial counts were described using a geometric mean and log standard deviation (GM ± Log10SD). Simple frequency distribution tables along with GM ± Log10SD were used as descriptive analyses for bacterial counts. A cross-tabulation to compare the two groups of the study (Room A with enhanced technique and room B with routine technique) was used. The chi-squared test was used for calculating significant differences between the groups whenever possible. The student t-test was used to determine if there was a significant difference between the geometric means of the two groups regarding the quantitative data with a normal distribution. The Mann Whitney test (U) was used to test the statistical significance difference between two groups of continuous data with a non-normally distribution. The McNemar test is used to compare the proportions of paired categorical data, particularly when the outcomes are dichotomous, such as before and after intervention. So, The McNemar test was used in this study to compare infection rates before and after an enhanced cleaning intervention in each room. The significance of the obtained results was judged at the 5% level with a t-test and a chi-squared test.