Impact of a multicomponent training intervention (Clean FrontLine) on microbiological cleanliness in Cambodian referral hospitals: a multicentre, stepped-wedge, cluster-randomised trial.

Abstract

Cleanliness of near-patient hospital surfaces is essential for preventing health care-associated infections and the spread of antimicrobial-resistant pathogens. Randomised evaluations of cleaning interventions have not been done in low-resource settings. We assessed the effectiveness of a hospital-based training intervention (Clean Frontline) to improve the microbiological cleanliness of near-patient surfaces. In this stepped-wedge, cluster-randomised trial in 13 Cambodian referral hospitals, we defined four steps (timings) that define the transition from control to intervention. All eligible public referral hospitals (district or provincial) in three selected provinces consented to participate. Pre-intervention, environmental cleaning practices remained unchanged. The multicomponent intervention selected, trained, and supervised facility cleaning champions, who in turn trained and supervised hospital cleaners. The primary outcome was microbiological cleanliness of near-patient surfaces, assessed using dipslides (a surface with <2·5 colony-forming units per cm² was classified as clean). 30 samples per hospital were collected monthly over 10 months. Outcome data collection and analysis teams were masked to treatment allocation. The primary outcome was estimated at surface level (primary analysis, odds ratio) and hospital level (risk difference), using an intention-to-treat approach and adjusted for a-priori confounders: temperature, patient numbers, beds per cleaner, and surface type. This trial is registered with ClinicalTrials.gov, NCT05540886, and is complete. Across the 13 participating hospitals, a total of 53 champions and 51 cleaners were trained. Outcomes were measured monthly between May 3, 2022, and March 23, 2023. We collected 3900 samples, 3822 of which were used in the analyses. We observed a positive, although non-significant, effect of the intervention on cleanliness in the surface analysis (odds ratio 1·39 [95% CI 0·95-2·03], p=0·081). The hospital-level analysis indicated a significant improvement of 5·04 percentage points (95% CI 0·76-9·33, p=0·026). Improving microbiological cleanliness of near-patient surfaces in hospitals in low-resource settings through the delivery of context-appropriate training and support is feasible. Further research should test this intervention with a wider number of clusters. Lessons learnt from the implementation will inform WHO roll-out of the training package. Who Gives A Crap and the Reckitt Global Hygiene Institute.