C. difficile & Environmental Decontamination for Long-Term Care

Transcription

1 C. difficile & Environmental Decontamination for Long-Term Care October

2 Today s Call is Provided by Telligen Telligen: The Medicare Quality Innovation Network (QIN)-Quality Improvement Organization (QIO) for Colorado, Iowa and Illinois QIN-QIO Program Purpose: To improve the efficiency, effectiveness, economy, and quality of services delivered to Medicare beneficiaries 2

3 C. difficile & Environmental Decontamination April Burdorf, RN, BSN, MPH, CIC Infection Prevention Unit Manager

4 Objectives Describe how the health care environment impacts the risk of C. difficile transmission. Distinguish between healthcare disinfectants and other disinfectants and/or cleaning products. Determine whether or not a disinfectant can be utilized in the healthcare environment by consulting the EPA list of approved surface disinfectants. Summarize methods that can be utilized to assess the adequacy of cleaning and disinfection processes

5 Anaerobic, gram positive, spore-forming bacillus Within the genus Clostridium, all of the organisms are associated with significant disease in humans. Some produce no toxins, some produce low level toxins and some are highly toxigenic Illness from toxin producing strains of C. difficile can cause illness ranging from mild to moderate diarrhea to pseudomembranous colitis, which can lead to toxic dilatation of the colon, sepsis and even death.

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9 How the environment impacts C. difficile

10 Reservoirs of C. difficile Humans Inanimate Objects Symptomatic Patients Items in the environment contaminated with C. difficile spores (e.g. hand rails, light switches) Asymptomatic Patients The level of environmental contamination is proportional to the severity of disease Hands of Healthcare Workers

11 Microbiologic features of C.difficile that favor a role for environmental transmission Stable in the environment for prolonged periods of time (spore-forming bacillus) Fecal-oral transmission Low inoculating dose Relative resistance to germicides (antiseptics and disinfectants) D.J. Weber et al./american Journal of Infection Control 41 (2013) S105-S110

12 Overview Basic practices are prevention measures that should be in place at all times. Facilities should consider adopting some or all of the special approaches whenever ongoing opportunities for improvement are identified or as indicated by risk assessment. Basic Practices Appropriate use of antimicrobials Hand hygiene per CDC/WHO recommendations Measure healthcare personnel adherence Contact Precautions for CDI patients Measure healthcare personnel adherence Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification to IP and clinical personnel of newly diagnosed CDI patients CDI surveillance, analysis, and reporting Special Approaches Antimicrobial stewardship program Hand hygiene with soap and water after glove removal following care of CDI patients Intensify measurement of adherence Presumptive Contact Precautions while laboratory results are pending Prolonged duration of Contact Precautions Intensify measurement of adherence Use of EPA-approved sporicidal disinfectant Assess adequacy of room cleaning Educate healthcare personnel, patients, and families Dubberke et al. Infect Control Hosp Epidemiol 2014; 35(6):

13 Overview Basic practices are prevention measures that should be in place at all times. Facilities should consider adopting some or all of the special approaches whenever ongoing opportunities for improvement are identified or as indicated by risk assessment. Basic Practices Appropriate use of antimicrobials Hand hygiene per CDC/WHO recommendations Measure healthcare personnel adherence Contact Precautions for CDI patients Measure healthcare personnel adherence Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification to IP and clinical personnel of newly diagnosed CDI patients CDI surveillance, analysis, and reporting Special Approaches Antimicrobial stewardship program Hand hygiene with soap and water after glove removal following care of CDI patients Intensify measurement of adherence Presumptive Contact Precautions while laboratory results are pending Prolonged duration of Contact Precautions Intensify measurement of adherence Use of EPA-approved sporicidal disinfectant Assess adequacy of room cleaning Educate healthcare personnel, patients, and families Dubberke et al. Infect Control Hosp Epidemiol 2014; 35(6):

14 Cleaning/Disinfection of Reusable Equipment

15 Defining who cleans what/when? Examples: Bandage scissors Therapy Equipment (splints, water baths, gait belts, parallel bars, ultrasound equipment, TENS units) Activities Equipment, manipulatives, Wii controllers Blood Pressure/Vital Sign Equipment, glucometers Lifts Contractors: Dental, Podiatry, Wound Care, Massage Therapy

16 Manufacturers Instructions for Use The Food and Drug Administration (FDA) requires manufacturers of reusable medical devices have the responsibility to support product label claims of reusability by providing complete and comprehensive written instructions for the handling, cleaning, disinfection Healthcare personnel have the responsibility to obtain and review manufacturers data and recommendations and to ensure that they have the necessary resources to follow the instructions thoroughly. If the instructions do not give instructions on how the item should be cleaned between individuals, it may not be intended for use on more than one person (e.g. glucometers)

17 Spaulding Classification:

18 Visual Method to Identify Clean Items Ready for Use Google images: methods to identify clean items

19 Disinfectants

20 Proper use of disinfectants Facilities must ensure proper preparation and use of disinfectants including appropriate: Dilution Storage Application Contact Time

21 Cleaners and Disinfectants Read the label first How to apply the product to a surface. How long you need to leave it on the surface to be effective (contact time). If the surface needs to be cleaned first and rinsed after using. Whether the product requires dilution with water before use. Precautions you should take when applying the product, such as wearing gloves or aprons or making sure you have good ventilation.

22 CLEANER Used to remove dirt, soil, dust, organic matter and germs (bacteria, viruses, fungi) Work by washing the surface to lift dirt and germs off so they can be rinsed away Rinsing is an important step in cleaning DISINFECTANT Chemical products that destroy or inactivate germs and prevent further growth Regulated by U.S. Environmental Protection Agency (EPA) Complete list can be found at the EPA website on next slide

23 C. Difficile and Spore Removal 1. Rutala et al. Infect Control Hosp Epidemiol 2012; 33(12): Gonzalez et al. Am J Infect Control 2015; 43:

24 EPA s Registered Antimicrobial Products Effective against C. difficile spores All EPA-registered pesticides must have an EPA registration number. (e.g., ) List K can be found at the following link: Alternative brand names have the same EPA registration number as the primary Distributors may sell products with formulations and efficacy identical to the primary product, they frequently use different brand names. These will have a three part EPA registration number (e.g )

25 Ultraviolet Light and Hydrogen Peroxide Fogging Data currently insufficient to recommend inclusion of these methods in a CDI prevention program 1 Standard room cleaning and disinfection found to be suboptimal when UV disinfection was used 2 Consistent cleaning attributed to 2 interventions: Dedicated team Supervisory housekeeping staff or IP staff checked rooms post cleaning Effectiveness of no-touch disinfection technologies in preventing CDI requires further evaluation Dubberke et al. Infect Control Hosp Epidemiol 2014; 35(6): Sitzlar et al. Infect Control Hosp Epidemiol 2013; 34:

26 Assess Adequacy of Room Cleaning

27 If it looks clean it must be clean Cleanliness vs. clean Visual assessment can identify only gross lapses in practice Difficult to assess compliance with cleaning policies and procedures Single-site quasiexperimental studies, have uniformly supported the value of ongoing interventions that objectively evaluate and programmatically improve the thoroughness of healthcare environmental cleaning

28 Direct Practice Observation Covert monitoring of disinfection cleaning can provide an objective assessment of individual ES staff performance and compliance with cleaning protocols. Swab Cultures Swab cultures are easy to use, the cost of processing, including isolate identification, the delay in analyzing results, the need to determine pre-cleaning levels of contamination for each object evaluated creates barriers to implementation. Agar Slide Cultures Can be utilized to study before and after cleaning aerobic colony counts. Could provide an easy method for quantifying viable microbial surface contamination. Fluorescent Markers Fluorescent gel, powder and lotion have been developed for the purpose of marking high touch surfaces prior to room cleaning. Powder and lotion can be easily seen, fluorescent gel typically dries transparent on surfaces. ATP Bioluminesence Measurement of organic ATP on surfaces using a luciferase assay and luminometer.

29 High touch surfaces Facilities must ensure adequate cleaning of high touch surfaces in the patient environment.

30 Examples of High-touch Surfaces

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34 Summary

35 Key Principles There is no substitute for meticulous cleaning 1,2,3 Cleaning reduces spores in the environment 2 Disinfectants with a sporicidal claim inactivate spores 2 Monitoring and feedback optimize performance 1 Policies should clearly define who is responsible for cleaning and disinfecting environmental surfaces and equipment 4 Cleaning The removal of organic debris using vigorous wiping and or scrubbing until all visible soil is removed 1 Disinfection Removal or inactivation of some or all pathogens on inanimate objects 1 1. Carling Am J Infect Control 2013; 41:S Rutala et al. Infect Control Hosp Epidemiol 2012; 33(12): CDC Guidelines for Environmental Control in Healthcare Facilities: 4. CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities: 35

36 References 1. Carling Am J Infect Control 2013; 41:S Rutala et al. Infect Control Hosp Epidemiology 2012; 33(12): CDC Guidelines for Environmental Control in Healthcare Facilities: 4. CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities 5. C. Diff Prevention Primer:

37 Questions?

38 Please Contact any of our Quality Innovation Network Representatives to Learn More Lisa Bridwell Deanna Curry Nell Griffin Elizabeth Schulte Kristen Ives NHSN support Sarah Wendelboe NHSN support This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy 11SOW-QIN-C2-10/03/