“Trash and Dash”: How Outsourced Cleaning Fuels the Hospital Infection Crisis

Which should take longer to clean: a hotel room or a hospital room?

The hospital room, of course. A hotel room must sparkle and shine, with crisply made beds and a fresh supply of towels; a hospital room must be cleansed of lethal pathogens.

Yet in this era of hospital budget cutting, cleaning crews often have far less time than the 40 to 45 minutes recommended for between-patient room disinfection — even less than the 30 minutes typically allotted to hotel housekeepers.

It’s not unheard of for a hospital crew to have “15 minutes to disinfect a room between gravely ill patients,” reports Dan Zuberi, Ph.D., a University of Toronto sociologist, in Cleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients.

Cleaners may even be told, “Get this room done in 10 minutes,” John Scherberger, president of the Healthcare Laundry Accreditation Council, told Infection Control Today.

What’s behind the hospital cleaning crisis: outsourcing.

The cleaning crews most likely to “trash and dash”— in other words, cut corners — are those employed by franchises of multinational companies (“Think McDonald’s with housekeepers instead of hamburgers,” Zuberi says) rather than by the hospitals they service.

With more U.S. and European hospitals outsourcing, facilities are increasingly vulnerable to the spread of hospital-acquired infections.

To be sure, outsourcing is just one driving force behind the hospital infection epidemic. “Abysmal” hand hygiene among healthcare workers is a huge contributor, as is the rampant misuse of antibiotics. And even when hospital cleaning is done well — by highly trained, motivated, and well-equipped staff cleaners — pathogens can proliferate. Some of the most dangerous bacteria, such as vancomycin-resistant Enterococcus (VRE), are notoriously resistant to even extreme disinfection efforts.

Nonetheless, outsourcing is a proven contributor to the spread of deadly microbes among hospital patients.

“Workers require proper qualifications, training, equipment, and decent work conditions to do their job well,” Zuberi writes, “but outsourcing has undercut the workers and their mission.

Zuberi spent three years tracking hospital cleaners in British Columbia, where legislation prompted all hospital cleaning to be outsourced and wages dropped by nearly 50%. Zuberi calls the change a “disaster,” both for cleaners and patients. Cases of VRE “skyrocketed,” and overall rates of hospital-acquired infections in British Columbia far exceeded rates of Canadian provinces that did not so extensively outsource their cleaning.

Numerous studies draw a direct line between hospital outsourcing and rates of dangerous infection.

For example, in a study of 126 English National Health Service hospitals, those using outsourced cleaners reported nearly 50% more methicillin-resistant Staphylococcus aureus (MRSA) infections than hospitals with in-house cleaners.

“Contracting out NHS services may save money, but this is at the price of increasing risks to patients' health,” wrote study co-author David Stuckler, Ph.D., a public health expert at the London School of Hygiene and Tropical Medicine.

Infection spread costs hospitals dearly, increasing readmission and mortality rates and causing temporary closures due to outbreaks. Patients who acquire infections from surgery spend, on average, an additional 6.5 days in the hospital and are five times more likely to be readmitted after discharge. Patients infected by an antibiotic-resistant “superbug” may spend an additional 16.9 days in the hospital. A single MRSA infection in the neonatal intensive care unit can extend the infant's stay by 40 days, at an extra cost of $160,000.

Concludes Stuckler: “When these full costs are taken into account, contracting may prove to be a false economy.”

American researchers concluded as much in a paper titled “Superbugs Versus Outsourced Cleaners.” Their verdict: superbugs win.

Their study of California hospitals found “strong evidence” linking outsourced cleaning to incidence of Clostridium difficile, a particularly dangerous bacterium whose spores can linger on sheets, floors, and toilets and is readily spread via equipment. Patients infected with C. difficile have suffered amputations and the loss of their bowels.

In the California study, 73% of hospitals that did not outsource cleaning reported C. difficile cases in the year studied. But among hospitals that outsourced much of their cleaning, infection incidence reached 91%.

Why Outsourcing Leads to Infection Spread

Though hospital cleaners are classified as “low-skilled” workers, their job actually requires significant expertise. Yet many cleaners, particularly those who are outsourced, “receive little or no training for what they are supposed to be doing,” Scottish microbiologist Stephanie Dancer, M.D., asserts in a review of hospital surface disinfection practices and their link to infection spread.

Cleaning a hospital is wholly unlike cleaning a hotel room or restaurant bathroom. Cleaners must know the right concentration for each chemical, which products can be used for which surfaces, how long each chemical must remain on a surface, how long a wipe should be used before disposal, and how often to replace the contents of a mop bucket so the water itself does not spread infection.

“You can make a room look clean without much training, but to make it microbiologically safe is really difficult,” says Ojan Assadian, M.D., president of the Austrian Society for Infection Control.

A toilet or a floor or a bed rail can appear sparkling but remain teeming with pathogens.

Not only are many outsourced cleaners poorly trained, but they also tend to lack sufficient pay, sick days, and opportunities for career progression — despite facing a daily risk of poisoning, scalding, needle sticks, and infection from pathogens they are working to eradicate.

“They feel devalued and ignored,” Zuberi writes.

For all these reasons, cleaners report they often do not clean to the level necessary. In Zuberi’s book, cleaners describe reusing contaminated cloths, gloves, and mops. “You start cutting corners,” one worker says. “You just cannot get it all done. Bathrooms, offices, hallways. Stuff gets missed.”

Furthermore, when cleaners are outsourced, problems that arise don’t get addressed right away or in person. Instead, issues are funnelled through third-party staffing managers who work remotely. So workers may feel less accountable to the hospital and less invested in learning from their mistakes.

How Hospitals Can Control the Spread of Infection

Numerous studies show that spending more on cleaning can help hospitals halt the spread of infection. For example, when the U.K. National Health Service deep cleaned 1,500 hospitals, at the cost of £120 million, the cleaning saved an estimated £143 to £263 million in infection-related expenses.

When hospitals do outsource, they must demand higher standards of the companies they hire, says Scherberger. “When [contractors] say 'We can do a room in 12 or 14 minutes,' hospitals should say, ‘We want it done properly and we know it's going to take 25 to 30 minutes, minimum."

Still, given the fiscal crises hospitals continue to face, facilities must look for more cost-effective ways to control the spread of infection.

“One of the solutions could be to reduce the number of bacteria in air to prevent the settlement of surfaces,” says Prof. Assadian.

In other words, air disinfection.

After all, the pathogens that contaminate hospital floors, bed rails, and stethoscopes often land on these surfaces after being launched airborne by an infected patient’s cough or sneeze. Even breathing can propel harmful microbes into the air.

These particles can travel via air currents throughout the hospital — unless they are inactivated before wreaking havoc. Low-temperature plasma technology, used in Novaerus portable units, can halt the spread of infection, destroying airborne pathogens on contact.

Disinfecting hospital floors, toilets, light switches, bed rails, wheelchairs, and the like is hard work that requires training and constant vigilance. It must nonetheless be done every day and to exacting standards.

All hospitals, however, require additional lines of defence against infections. With plasma technology, air can be disinfected automatically, safely, cost-effectively, and 24 hours a day — without the need to train or motivate the hospital’s cleaning crews.

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