Quality control of hospital cleaning is a crucial part of efforts to prevent healthcare-associated infections. Since 2017, there has been a Swedish cleaning standard designed to help with this very issue. The standard focuses on surfaces in close proximity to patients—that is, areas where the risk of infection transmission is highest.
The cleaning standard, a relatively brief document of about a dozen pages, is titled “Cleaning and Sanitation to Reduce the Spread of Infection in Healthcare” and is designated SS 8760014:2017. Its description states that it sets out quality criteria and requirements for routine cleaning and quality control. So what kind of standard is this?
The standard is based on the Nordic cleaning standard INSTA 800, which describes a general system for visual quality control, but differs from it in that it focuses specifically on healthcare hygiene cleaning. In this respect, it is similar to the Danish cleaning standard DS2451-10, which is a supplementary standard to INSTA 800. The difference from DS2451-10, however, is that SS 8760014 is essentially an independent standard.
The standard’s basic concept – hygiene classes
A key feature of the new Swedish standard is the introduction of hygiene classes and high-risk surfaces—that is, surfaces in close proximity to patients or other surfaces that are frequently touched and may pose a risk of spreading infection.Facilities are divided into four hygiene classes based on infection risks and the extent to which patients spend time there:
- Hygiene Class 0: No patients are expected to be present.
- Hygiene Class 1: brief passage or stay by patients.
- Hygiene Class 2: care, treatment, and reception of patients.
- Hygiene Class 3: premises with specific cleanliness requirements.
In facilities classified as hygiene classes 2 and 3, surfaces with a high risk of infection must be identified. This may sound like a lot of surfaces to keep track of, but in practice, the high-risk surfaces are almost always the same for each type of room. The standard provides several examples, as shown in the image below and in Table 1.
Table 1: Examples of surfaces with a high risk of infection in hygiene classes 2 and 3
| At-risk areas | Description |
|---|---|
| Patient bed | Parts of a hospital bed: e.g., bed rails, examination table/stretcher, operating table, examination chair |
| Bathroom fixtures | Toilet seat, sink, faucets, bathtub, shower chair/trolley, toilet seat riser |
| Table surfaces | Nightstands, changing tables, tables in patient dining rooms/day rooms, surfaces for preparing medications, work surfaces |
| Technical installation (fixed or mobile) | Light switch, oxygen outlet, bedside lamp, alarm button, examination lamp, surgical lamp, control panel, remote control, door opener |
| Handles and grips | Handrails, grab bars, chair armrests, wall grips, shower grab bars, grab bars |
| Wheeled mobility aids | Contact surfaces on walkers, wheelchairs, and walking frames |
| Tripod | Waste bin, dish rack, dish drainer, hand sanitizer dispenser, soap dispenser, cup holder, paper towel dispenser |
| Shielding | Partition screen, curtain |
| Medical devices | Anesthesia station, incubator, ultrasound machine, ventilator, infusion pump |
New requirements for the cleaning process
The standard sets requirements for organization, communication, cleaning instructions, cleaning procedures, cleaning areas, and cleaning equipment. Various examples are provided regarding cleaning frequency and workflows for routine cleaning.
One section of the standard addresses staff qualifications. In addition to requirements for cleaning training and basic knowledge of healthcare hygiene, staff must be able to speak Swedish in order to understand instructions and assimilate procedures and training. Staff must pass written and practical exams.
Requirements for the storage and cleaning of cleaning supplies are also included. To prevent cross-contamination, the cleaning room must be adapted and designed to allow for the separate storage and handling of clean and dirty items. Reusable cleaning equipment must be capable of being cleaned through a controlled process so that it remains functional throughout the product’s specified service life.
Visual inspections
The standard’s visual assessment system for quality control is largely based on INSTA 800. The object groups (ceiling, wall, floor, interiors), accessible and hard-to-reach dirt, quality levels (1–5), quality profile, and classification of contamination groups are essentially the same. However, the classification of inspection units is simplified somewhat to apply only to the premises and the number of contamination instances per object group and per 15 m² of floor space.
The quality control provisions in the new standard differ primarily in two additional requirements that apply to facilities classified as hygiene classes 2 and 3. First, no contamination is permitted on surfaces with a high risk of infection. Second, no presence of feces, vomit, blood, or other bodily fluids is permitted on any surfaces.
Cleaning quality checks must be conducted at least once a quarter in accordance with the standard.
Measuring invisible dirt
At Hygiene Diagnostics, we believe one of the standard’s greatest strengths is that it specifies testing methods (ATP, UV light, and microbiological testing) that can be used to monitor surfaces with a high risk of infection. It also includes proposed threshold values (see Tables 2 and 3 below).
Furthermore, the standard provides a detailed example of a sampling plan involving a statistical selection of surfaces. The purpose of this plan is to assess the cleaning quality of a hospital, clinic, etc., with regard to invisible contamination. The sampling plan can be used as part of ongoing quality monitoring and when changing cleaning methods or implementing a new cleaning organization.
Table 2: Microbiological limit values SS 8760014 for hygiene classes 2 and 3.
| Bacterial level | Pathogens |
|---|---|
|
APPROVED ≤ 5 CFU per cm² |
APPROVED ≤ 1 CFU per cm² |
Table 3: ATP SS 8760014 for different quality levels within hygiene classes 2 and 3. The limit values in the table below are given in femtomoles (see post on conversion to RLU values).
| Quality Level 5 | Quality Level 4 |
|---|---|
|
GODKÄND < 25 femtomol per 100 cm² |
GODKÄND < 50 femtomol per 100 cm² |
|
BORDERLINE CASES 25–50 femtomoles per 100 cm² |
BORDERLINE CASE 50–100 femtomoles per 100 cm² |
|
NOT APPROVED* >50 femtomoles per 100 cm² |
NOT APPROVED** >100 femtomoles per 100 cm² |
* Clean-Trace ATP-meter: Not Approved >250 RLU (Relative Light Units)
Clean-Trace ATP-meter: Not Approved >500 RLU (Relative Light Units)
What does the standard entail?
It may be too early to say whether the standard will gain traction among Sweden’s municipalities and county councils. Updates to the standard are currently underway, which may address some of the weaknesses for which it has been criticized—such as the fact that the visual method is not as effective as INSTA 800.
We believe that this standardis important as a first step toward better oversightand fewer quality issues in healthcare cleaning. Common sense tells us that this will lead to a reduction in healthcare-associated infections, which are currently all too prevalent in our hospitals.
If you’d like to learn more about the standard or objective measurement methods, please check out our courses. If you have any questions, feel free to contact:
Frank Axelsson, tel: 0707 912103.