NOVEMBER 9, Palo Alto, CA. Stanford University Medical Center PRESENTED BY

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1 PRESENTED BY NOVEMBER 9, 2017 Stanford University Medical Center Palo Alto, CA

2 Exposure Concerns Related to Disinfection Techniques Erica J. Stewart, HEM, CIH, FAIHA NEH&S Principal Consultant Kaiser Permanente Allison Jouras, ASP, HEM Senior Consultant BSI EHS Services and Solutions

3 Agenda Kaiser Permanente Case Study Protecting our people when considering a new disinfectant

4 Objectives Understand the considerations when comparing two disinfectants Recognize organizational barriers that may exist when implementing a new disinfectant Be aware of items to consider when planning the roll-out of a new disinfectant

5 Selecting Surface Disinfectants: A Case Study Erica J. Stewart, HEM, CIH, FAIHA NEH&S Principal Consultant Kaiser Permanente

6 A Tale of Two Towelettes Ready-To-Use 0.63% sodium hypochlorite pre-wetted disposable towelettes dispensed from a canister with a small aperture top opening Improved hydrogen peroxide (HP)/peroxyacetic acid (PAA) disinfectant diluted in a closed system to ~ 0.9% HP, 0.2% PAA, and 0.25% acetic acid and dispensed onto microfiber reusable towelettes in a covered bucket

7 Efficacy Table A.1 Comparison of Contact Time and Temperatures for Species of Interest Data from: Literature Product testing results Product specifications US EPA registration

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10 C. diff. Disk Carrier Test Method Efficacy of liquid sporicides on nonporous and porous surfaces

11 Effectiveness Influenced by: Wiping method (pressure, time, motion) Disinfectant load on wipe Surface type and condition Surface characteristics Wipe materials

12 Effectiveness (cont d.) Limited information published No standardized effectiveness test method Differences among surface and wipe types Lab testing vs. field application Variation in cleaning methods

13 Efficiency (Cost-Effectiveness) Cost per wipe Pre-cleaning step, post-disinfection rinse? Dwell time (reapplication?) Surface material compatibility

14 Bleach vs. HP/PAA RTU bleach wipes easier to deploy HP/PAA does not require pre-cleaning or rinsing RTU bleach shorter dwell time HP/PAA not corrosive to surfaces Both have health & safety considerations

15 Health & Safety Considerations Table A.2 Occupational and Environmental Health and Safety Parameters Data from: Literature (including online databases) Safety data sheets Product testing results Product specifications US EPA registration

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18 Bleach Wipes Pros RTU convenient Staff acceptance Minimal eye and skin toxicity Not ignitable, reactive, or toxic waste Cons Inappropriate personal care use Pre-cleaning step Respiratory system asthmagen Corrosive waste, oxidizer Surface incompatibility requires rinse No established OEL or monitoring method

19 HP/PAA Wipes Pros One-step cleaner/ disinfectant Reusable towelettes Not a sensitizer Not corrosive, ignitable, reactive, toxic waste Established OELs and monitoring methods Cons Dilution of concentrate (concentrate has severe hazards) Staff acceptance (not) Respiratory system asthmagen? HP may be carcinogenic oxidizer

20 Air Monitoring Data Bleach HP/PAA (unpublished) HP <5% 8-Hr OSHA PEL PAA ~50% ACGIH TLV

21 Health & Safety Considerations Personal factors Spill and splash potential PPE selection Face/eyewash availability Disposal

22 Conclusions?

23 Selecting Surface Disinfectants: Protecting Our People Allison Jouras, ASP, HEM Senior Consultant BSI EHS Services and Solutions

24 Selecting a New Disinfectant Need to use to prevent patient infections Cannot use at the expense of staff safety

25 Selecting a New Disinfectant Many priorities to take into consideration: - Patient and employee safety - Infection rates - Ease of use - Staff and patient perception of cleanliness and hazardous properties - Regulatory compliance These may seem independent of one another, but there is a common thread: - Environmental Services (EVS) staff

26 How Priorities Are Affected by EVS Patient and employee safety Slips/Trips/Falls Hazardous exposures Body mechanics during use Storage, use, and disposal Spill response Regulatory compliance Infection rates Correct use of product Staff talk amongst themselves and others Facial expressions and behaviors indicating concern/dissatisfaction with product use Staff and patient perception of cleanliness and hazardous properties Ease of use Staff more likely to use product correctly if it is easy to use

27 The Balancing Act How do we make sure everyone goes home safely at the end of the day? Execute a proactive roll-out and plan for reactive response

28 Proactive Roll-Out: Evaluate Your Current State Procurement process: What gaps could lead to a new disinfectant showing up onsite without EH&S knowledge? Does EVS workflow for reviewing new disinfectants involve EH&S? EVS and EH&S: Does EVS see EH&S as a resource or a barrier? Does EVS understand what role EH&S plays in regards to their operations?

29 Proactive Roll-Out: Evaluate Your Current State EVS and hazards - Does EVS management understand: Why risk assessments for each product are crucial to staff safety? That vendor messaging about safety hazards and safety measures does not equal EH&S review? That vendor safety training does not equal EH&S safety training? That EH&S is advocating for EVS staff safety? Infection Control (IC): Do they see infection rates and patient safety as more important or equal to employee safety? What role does EH&S have in approval of product for use at your medical center in relation to IC and EVS? Is EH&S empowered to stop product use if there s an unmitigated safety risk?

30 Proactive Roll-Out: Risk Assessment Question the Safety Data Sheet (SDS) Are hazards appropriately represented? Hold vendor and manufacturer accountable Arrival, transport within the facility, storage, concentrate vs. diluted solutions, access controls, spill response, disposal of concentrate and diluted solutions, etc.. Ensure risk assessment process represents lifecycle of product at your institution

31 Proactive Roll-Out: Risk Assessment Involve IC and EVS in Risk Assessment process: Gemba/tabletop proposed product use with the vendor, EVS, and IC Point of entry onsite through disposal Bring product onsite for demo of use by vendor Experience product use as EVS staff will Include all vendor-provided equipment necessary for product use (e.g. dispensing stations) Benchmark with similar institutions: Conduct your own risk assessment though Be aware of vendor messaging related to safety risks: The diluted solution is safe for staff to handle without gloves on May need to educate the sales rep/vendor about hazards

32 Proactive Roll-Out: Safe Handling and Use Reference materials and safety postings Establish expectations for what materials shall be at point of use and access to training materials Identify what will need to be created, who will be responsible for doing so, and establish reference material expectations Make posting/access to reference materials a condition for use Personal Protective Equipment (PPE): Concentrate and diluted solution Use and storage areas Transport throughout facility Safety showers and eyewashes

33 Proactive Roll-Out: Safe Handling and Use EVS staff training: Language barriers for English-as-a-secondlanguage speakers Comprehension of how to use the product vs. comprehension of safety-related information Unjustified fears arise from lack of information/comprehension

34 Proactive Roll-Out: Safe Handling and Use EVS staff training: Vendor training vs. EH&S training requirements Vendors may provide EVS training materials that include all required safety information Incorporate mandatory EH&S training review Ensure EH&S is on-hand at all trainings to answer safety-related questions Incorporate rounding in the initial days after implementation to verify safe handling and use Address what harmful exposure really means for that product Unit and Physician messaging

35 Reactive Roll-Out: Anticipate Issues As Best You Can Create action plans as necessary for anticipated issues: Media plays to people s fears so see what s available to the public Benchmark with other institutions about what issues they ve encountered Identify staff confidantes and stay in communication with them Determine if proactive exposure sampling may be worth the investment

36 Summary Remind colleagues that the goal is to ensure that everyone goes home safely at the end of the day (staff and patients) Include colleagues in the risk assessment process Address the life-cycle of the product Question the product materials if they seem inadequate Ensure staff training is adequate and can be comprehended Try to anticipate issues, but we can t anticipate everything

37 Thank you for your time!