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Background: Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016–2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. Methods: A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. Results: Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. Conclusions: A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

BACKGROUND: Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia.METHODS: A stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention's feedback loop will provide the teams with a summary of these patients' risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention's implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention.DISCUSSION: This intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment

Background: Environmental cleaning is an important approach to reducing healthcare-associated infection. The aim of this short research paper is to describe changes in the efficacy of post-discharge cleaning by examining the amount of bio-burden on frequent touch points (FTPs) in patient areas, using a validated Adenosine Triphosphate (ATP) bioluminescence sampling method. In so doing, we present findings from a secondary outcome of a recent trial, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study. Methods: The REACH study used a prospective, stepped-wedge randomised cluster design. Cross sectional ATP sampling was conducted at three of the 11 participating hospitals. At each hospital, during the control and intervention phase of the study, six Frequent Touch Points (FTPs) were sampled: toilet flush, bathroom tap, inside bathroom door handle, patient call button, over bed tray table, and bed rails. Results: Across the three hospitals, 519 surfaces in 49 rooms (control phase) and 2856 surfaces in 251 rooms (intervention phase) were sampled. Bedroom FTP cleaning improved across all three hospitals. The cleaning of bathroom FTPs was generally high from the outset and remained consistent throughout the whole study period. Average cleaning outcomes for bathroom FTPs were consistently high during the control period however outcomes varied between individual FTP. Changes in cleaning performance over time reflected variation in intervention effectiveness at the hospital level. Conclusion: Findings confirm improvement in cleaning in the FTPs in bedrooms, demonstrating improvements in discharge cleaning aligned with the improvements seen when using fluorescent marking technology as a marker of performance.

Background Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016–2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. Methods A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. Results Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. Conclusions A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Background: 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. Methods: 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. Findings: 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 fro

Background The Researching Effective Approaches to Cleaning in Hospitals (REACH) study tested a multimodal cleaning intervention in Australian hospitals. This article reports findings from a pre/post questionnaire, embedded into the REACH study, that was administered prior to the implementation of the intervention and at the conclusion of the study. Methods A cross-sectional questionnaire, nested within a stepped-wedge trial, was administered. The REACH intervention was a cleaning bundle comprising 5 interdependent components. The questionnaire explored the knowledge, reported practice, attitudes, roles, and perceived organizational support of environmental services staff members in the hospitals participating in the REACH study. Results Environmental services staff members in 11 participating hospitals completed 616 pre- and 307 post-test questionnaires (n = 923). Increases in knowledge and practice were seen between the pre-and post-test questionnaires. Minimal changes were observed in attitudes regarding the role of cleaning and in perceived organizational support. Conclusion To our knowledge, this is the first study to report changes in knowledge, attitudes, and perceived organizational support in environmental services staff members, in the context of a large multicenter clinical trial. In this underexplored group of hospital workers, findings suggest that environmental services staff members have a high level of knowledge related to cleaning practices and understand the importance of their role.

The Researching Effective Approaches to Cleaning in Hospitals (REACH) project aimed to evaluate the effectiveness of an evidence-based cleaning bundle in 11 major Australian hospitals in 2016-2017. The bundle included training for environmental and hotel services staff, audits of the thoroughness of cleaning, and activities at each hospital to raise the profile of staff and highlight the importance of hospital cleaning. The REACH trial used a stepped-wedge randomised controlled study design. Data were collected in a variety of ways, including pre-and post-knowledge and attitudes questionnaires and discussion groups with environmental and hotel services staff, and through systematic review of each hospital's cleaning program. An audit and feedback process was part of the cleaning bundle, and included the use of an ultraviolet gel dot marking system to assess cleaning. Improving hospital cleaning is complex. Existing cleaning practices were diverse, as were the policy, contract, staffing and governance arrangements. Most hospitals demonstrated improvement in ward cleaning over the trial period and most staff reported that participating in the trial was a positive experience. Common themes emerged about the factors that support and sustain practice improvement in hospital cleaning. These will be discussed in detail, along with the outcomes of the audit and feedback activities.

The Researching Effective Approaches to Cleaning in Hospitals (REACH) Study used an implementation science approach to inform the structured yet pragmatic trial of an environmental cleaning bundle intervention in 11 Australian hospitals. This allowed for the development of a tailored implementation plan that responded to the evidence-practice gap at each hospital and aimed to support the practice change required for effective cleaning bundle implementation. After the trial, the project team reviewed the implementation plan to assess the extent of implementation of the bundle and the key enablers and barriers. This presentation will provide a unique insight into the lessons learned when implementing the REACH Study. It will include useful advice for infection control professionals wanting to implement effective change in their cleaning programs, and researchers interested in how to improve infection prevention trials.

Introduction The Researching Effective Approaches to Cleaning in Hospitals (REACH) study evaluated the effectiveness of a novel cleaning bundle intervention in 11 major Australian hospitals in 2016-2017. It was essential for effective bundle implementation that there was close collaboration with staff at each hospital who perform hospital cleaning, and the trial activities reflected the local staff context and characteristics. Multiple approaches were used to engage with environmental services staff and to promote ownership of the cleaning bundle at each hospital. Methods Pre-trial questionnaires, that aimed to identify environmental services staffs’ baseline knowledge about cleaning, and their attitudes and perceptions of their role and organisational support were completed by 616 people across the 11 hospitals (35.63% of total staff). The REACH study team facilitated 25 discussion groups (n=223) to identify local issues and contextual factors around hospital cleaning work. Data from these activities were used to tailor the cleaning bundle and plan the hospital-specific staff engagement. Post-trial, the questionnaires were repeated at each hospital (n=307) and questions included about staff experience of participating in the REACH trial. Results Analysis of pre- and post-trial questionnaire results indicated minimal increase in attitudes related to perceptions of organisational support. However, post-trial (n=307), 64% of staff agreed they felt recognised for their participation in the trial (range 33-90%) and 68% agreed they felt supported throughout the trial (range 44-100%). Thematic analysis of post-trial feedback will be presented. Discussion Providing tailored and context-responsive activities in each hospital supported the research trial implementation. In terms of increasing staff engagement with the research, the bundle included activities to support and recognise the importance of environmental services staff within a hospital’

Background Implementing change in hospital cleaning is difficult; it requires consideration of existing practices and context. The Researching Effective Approaches to Cleaning in Hospitals (REACH) study was a stepped-wedge trial of a multimodal cleaning bundle in 11 Australian hospitals, 2016-2017. We used implementation science, adapting the Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, to tailor delivery of the intervention at each site. This included quantifying evidence-practice alignment and extent of contextual enablers at each hospital. Methods Baseline data about infection prevention and hospital cleaning were collected using staff questionnaires, interviews, discussion groups and a document review. For each hospital, these data were systematically mapped and assessed according to the key elements of the framework and the cleaning bundle. Two researchers independently rated items on a 0-5 scale, then reviewed and agreed a final score. Ratings were summarised on a series of three web diagrams: for alignment of practice, and for staff and site implementation readiness. This provided a visual picture of the gaps and barriers to be addressed. Results For the intervention, four hospitals had low levels of practice alignment (≤3) in four or more of the bundle components; only two hospitals had high levels (≥4) in more than 3 areas. Five hospitals had high (≥4) alignment with the evidence for cleaning product use; two of these had high ratings for cleaning technique, and one site had good technique but low (≤2) product alignment. Ten hospitals had gaps in audit and feedback practice (≤3), and eight of these hospitals had gaps in at least one of the communication and training components. Four of the hospitals with communication scores ≥3 had scores for all staff and site readiness items of ≥3. Conclusion Using a quantitative representation of the practice and context issues to be addressed at each h

Background Environmental cleaning is a vital element of an infection prevention program. There are gaps in understanding how hospital cleaning works in the real world, making improving hospital cleaning a challenge. Baseline data collected for the Researching Effective Approaches to Cleaning in Hospitals (REACH) study provides new information about the state of play of current hospital cleaning in Australia. Methods The REACH study used a stepped-wedge randomised controlled study design in 11 major Australian hospitals. Pre-trial data collection activities included a structured review of each hospital’s infection prevention program; questionnaires to assess cleaning staff attitudes, knowledge, and perceived organisational support; and discussion groups with cleaning staff to explore local enablers and barriers to their work. These data were analysed to identify commonalities across sites. Results Major variation was observed. All hospitals had established cleaning programs but with varying elements and priorities, particularly in the composition and responsibilities of the cleaning workforce, and in processes used to audit performance and give feedback. This variation showed no consistency related to hospital size or location. Questionnaire responses identified two hospitals with both limited audit and training processes and lower levels of perceived organisational support; two others with consistently high levels of support, while other hospitals varied across the items. A consistent theme from the discussion groups was a high value placed on recognition of the work of cleaning staff, although there was variation in what feedback, reward and recognition processes were considered optimal, and what actually happened in practice. Participants also reported issues relating to access to appropriate equipment and product supply, and the impact this has on cleaning work. Conclusions This snapshot of hospital cleaning in Australia highlights differences in the implementati

Highlights • There are variations in the auditing process used to evaluate environmental cleanliness. • Different cleaning practices, product use and training for cleaning staff occur in Australian hospitals. • These variations present a number of challenges for research and monitoring of and standards for cleanliness. Abstract Background The purpose of this paper is to highlight the range of cleaning practices and processes in 11 Australian hospitals and to discuss the challenges this variation poses to the implementation of clinical trials or changes to hospital cleaning practices. Methods A cross-sectional study design was used to determine cleaning practices and processes in hospitals participating in the ‘Researching Effective Approaches to Cleaning in Hospitals’ (REACH) study. A standardised template and approach was used to collect information. Data collection activities included structured on-site discussions, a review of hospital practices and a document review of policy and procedural documents related to cleaning. Results Variations in the auditing process used to evaluate environmental cleanliness, cleaning practices, product use, training and communication pathways available to cleaning staff were identified. There was also variation in workforce structure and responsibilities for cleaning. Conclusion This paper is the first to describe the differences in cleaning practices between Australian hospitals. The variations identified present a number of challenges for the conduct of research and have important implications for both monitoring of and standards for cleanliness. These challenges include implementing a practice change or cleaning study where hospitals have different processes, practices and structures. Keywords Cross infection; Infection control; Hospitals; Health services; Housekeeping; Maintenance; Hospital administration; Translational research; Environment

Background Multi-centre studies generally cost more than single-centre studies because of larger sample sizes and the need for multiple ethical approvals. Multi-centre studies include clinical trials, clinical quality registries, observational studies and implementation studies. We examined the costs of two large Australian multi-centre studies in obtaining ethical and site-specific approvals. Methods We collected data on staff time spent on approvals and expressed the overall cost as a percent of the total budget. Results The total costs of gaining approval were 38 % of the budget for a study of 50 centres (mean cost AUD $6960 per site) and 2 % for a study of 11 centres (mean cost AUD $2300 per site). Seventy-five and 90 % of time was spent on repeated tasks, respectively, and many time-consuming tasks, such as reformatting documents, did nothing to improve the study design or participant safety. Conclusions Improvements have been made to the ethical approval application system, but more gains could be made without increasing risks of harm to research participants. We propose that ethical review bodies and individual sites publish statistics on how long they take to process approvals which could then be nationally benchmarked. Keywords Research ethics Ethical review Multi-centre study Australia

Background and aims The Researching Effective Approaches to Cleaning in Hospitals (REACH) study, aims to evaluate the effectiveness of a novel cleaning bundle intervention in 11 major Australian hospitals. Outcome measures include healthcare associated infection rates, cleaning performance and cost effectiveness. Implementing a complex intervention in multiple, large healthcare environments requires a systematic and rigorous approach to ensure authenticity and trial integrity. The REACH study is using the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to inform the implementation of the environmental cleaning bundle in each hospital. Methods Using the iPARIHS framework constructs (innovation, recipients, context and facilitation), we will map the hospital characteristics, including infection prevention policies and practices, and environmental services staff knowledge and attitudes. We will use this information to develop a tailored implementation strategy for each site. During the trial we will assess and monitor the bundle implementation and local impact using tools based on the framework. Collecting this contextual and process information will allow the study team to respond to implementation issues. Further, it will assist in evaluating intervention and implementation delivery and fidelity. After the trial, information collected about the implementation process will be reviewed to develop an understanding of how and why the intervention did or did not work at each site. Conclusion A local implementation plan, informed by the iPARIHS framework, will support effective operationalisation of the REACH cleaning bundle intervention. Additional monitoring of the implementation process will assist with trial site comparisons, supporting future replication and scalability.

Background The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will evaluate the impact of a novel environmental cleaning bundle in 11 hospitals around Australia. In each trial site we will collect a range of data, including healthcare associated infection rates, associated costs and changes in the thoroughness of cleaning. While these data will assist in determining the overall effectiveness and cost-effectiveness of the cleaning bundle it is important to understand what aspects of the practice change process worked, under what conditions, and why. Methods The project team will systematically document and review the implementation process at each hospital site. To frame this process evaluation we have developed a logic model to identify what assumptions are being made and what expectations there are about how the process will work at each trial hospital. Results The model outlines a proposed link between trial processes and intended trial outcomes. It shows the flow of activities and potential impact of local context and external factors in implementing change. Conclusion The process of developing a logic model – a pictorial representation of key trial inputs, outputs and outcomes – has clarified the underlying assumptions involved in improving hospital environmental cleaning. This will inform a systematic evaluation of the change process in each of the participating hospital sites, which will assist with translation of trial outcomes to other hospital settings and to the environmental services workforce.

Background: The Researching Effective Approaches to Cleaning in Hospitals (REACH) study is a partnership project funded by the National Health and Medical Research Council (NHMRC). It aims to evaluate the effectiveness and cost-effectiveness of a novel cleaning bundle intervention. Eleven major Australian hospitals are participating in this research, with the trial component running from May 2016 until July 2017. Methods: The REACH trial uses a stepped wedge study design. This design ensures each trial site receives an eight week control period, followed by a randomly allocated intervention period between 20 and 50 weeks. Participation in such a major research activity requires a significant commitment from each trial hospital. To ensure this commitment is sustainable, the REACH study team will maintain a high level of contact with each site. Local site teams will also be a key aspect of conducting the research. During the pre-trial phase a research team will be established at each hospital. This team will include an infection prevention and control practitioner and an environmental services lead. Additional site team members will reflect local context and team structure. Site teams will assist with administrative activities for the trial, data collection and, importantly, the effective engagement of environmental services staff. Results and Conclusion: The local site team will be essential for successful implementation of the REACH research activities. Examples of site teams’ composition and activities will be showcased to highlight diversity and the value of strong collaboration in supporting behaviour change and quality improvement initiatives.

Background The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices. Methods/design The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle. The study uses the integrated Promoting Action on Research Implementation i