Economic evaluation of enhanced cleaning and disinfection of shared medical equipment

I’ve written this blog in preparation for Journal Club on Wednesday (register here) about an economic evaluation of the CLEEN study, which was a stepped-wedge randomised controlled trail of enhanced cleaning and disinfection. The evaluation concluded that the intervention was not only cost effective but cost saving due to the observed reductions in HCAI!

Why I chose this article

While environmental cleaning and disinfection is recognised as an important component of infection prevention, it can be seen as a soft target when budget cuts come. Part of the issue is the quality of the evidence (although this is improving – and point me to an IPC intervention with higher quality evidence…!) – but the lack of thorough economic evaluations of relevant interventions is another barrier to investment. This article is one of the first thorough economic evaluations of an intervention around enhanced cleaning and disinfection in hospitals.

Background

There is an increasing body of evidence that improving hospital cleaning and disinfection reduces the risk of HCAI and the transmission of antimicrobial-resistant microbes. There is also some limited evidence of cost-effectiveness for some cleaning and disinfection interventions.

• Stephanie Dancer modelled the impact of an extra ward cleaner over 12 months in a ward cross-over study. The cleaner cost £12k per year, and each MRSA infection was assumed to cost £9k. The intervention was associated with a 27% reduction in MRSA infection and the intervention was cost saving, was estimated savings between £30k and £70k per annum.
• The REACH study was a cost-effectiveness analysis of a randomised controlled trial of a cleaning bundle to reduce HCAI in 11 Australian hospitals. Implementing the cleaning bundle cost AUD$349,000 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 $4,684 per QALY gained. There
  was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices.

The CLEEN study was a stepped-wedge cluster randomised controlled trial of 3 hours additional hours cleaning each day of shared mobile medical equipment. The study was associated with a significant improvement in cleaning performance, as judged by the removal of fluorescent markers, and a significant reduction in HCAI from 14.9% in the control phase to 9.8% in the intervention phase, a 34% reduction.

Design and methods

• Study type: Economic evaluation from stepped-wedge cluster randomised trial.
• Setting: Ten adult acute-care wards in a tertiary hospital in Australia.
• Population: 5,002 inpatients (mean age 71.6 years).
• Intervention: A multimodal cleaning bundle, including additional dedicated cleaning hours, education and refresher training, and auditing and feedback.
• Comparator: Usual care (cleaning by clinical staff).
• Analysis: Decision-tree model from a hospital costing perspective; incremental cost-effectiveness ratio (ICER) calculated using Monte Carlo simulations.

Key findings

• Cost savings: For 1,000 patients, intervention costs were $1.51M AUD vs $2.16M AUD for usual care, a saving of $642,010 AUD.
• These figures are based on HCAIs reducing from 130 (usual care) to 100 (intervention), avoiding 30 infections and 384 excess bed-days per 1,000 patients.
• Probability of cost-effectiveness: 90.5% at $0 willingness-to-pay threshold; 99.9% at $20,000 per infection avoided.
• Scenario analyses: Even with biodegradable wipes or halved effectiveness, intervention remained cost-saving.

Strengths and limitations

• Economic evaluation based on a rigorous stepped-wedge cluster randomised design.
• Probabilistic sensitivity analysis enhances robustness.
• Real-world costing perspective aligns with hospital decision-making.
• Single-site study may limit generalisability.
• Conservative assumptions (e.g., one HCAI per patient) likely underestimate savings.
• Excludes societal benefits and quality-adjusted life years.
• The rate of HCAI was high to begin with (14.9%, compared with 7.6% in the UK). The second scenario analysis with a reduced level of effectiveness provides some reassurance that the intervention would remain cost effective with a lower starting rate of HCAI.

Points for discussion

• Should we invest in dedicated resource targeted at cleaning and disinfection of shared medical equipment on the basis of these findings?
• If so, what would be the best model of delivering this (i.e. dedicated role or spread across existing roles)?
• Should IPC guidelines mandate structured cleaning bundles for shared equipment?
• Should we audit the cleaning and disinfection of shared medical equipment?
• What role does sustainability play in infection prevention - are biodegradable consumables economically viable at scale?

What this means for IPC

The CLEEN study provides compelling evidence that enhanced cleaning and disinfection of shared medical equipment is not only clinically effective but probably cost saving and almost certainly cost effective. For IPC teams, this reinforces the need to prioritise structured cleaning and disinfection interventions, supported by training and auditing. And so, we can conclude that CLEENING is cost effective!