A Bundle Approach to Environmental Cleaning and Disinfection

A Bundle Approach to Environmental Cleaning and Disinfection Nancy L. Havill MT(ASCP), CIC Yale-New Haven Hospital New Haven, CT Disclosures:None

Objectives Describe the level of contamination in the healthcare environment Discuss the role of the environment in transmission of pathogens Review best practices for cleaning and disinfection Define monitoring methods for evaluating Cleanliness Discuss No Touch Room Disinfection Systems

Contamination in the Patient Zone

Frequency of Environmental Contamination: MRSA Present in Stool versus No MRSA in Stool Boyce et al. Infect Control Hosp Epidemiol. 2007;28:1142-7

How Long Do Organisms Survive? Organism Clostridium difficile (spores) Acinetobacter spp. Enterococcus spp. including VRE Pseudomonas aeruginosa Klebsiella spp. Staphylococcus aureus, inc. MRSA Survival time 5 months 3 days to 5 months 5 days 4 months 6 hours 16 months 2 hours to > 30 months 7 days 7 months Norovirus (and feline calicivirus) 8 hours to > 2 weeks 1 SARS Coronavirus 72 hours to >28 days 2 Influenza Hours to several days 3 Adapted from Kramer et al. BMC Infect Dis 2006;6:130. 1. Doultree et al. J Hosp Infect 1999;41:51-57. 2. Rabenau et al. Med Microbiol Immunol 2005;194:1-6. 3. Bean et al. J Infect Dis 1982;146:47-51.

Increased Risk From Prior Room Occupant Nseir A. baumannii Shaughnessy C. difficile Drees VRE Drees VRE (2 weeks) Nseir P. aeruginosa Huang VRE Huang MRSA +58% +55% +49% +42% +37% +28% +71% 0 1 2 3 4 Odds ratio Otter et al. Am J Infect Control 2013;41(5 Suppl):S6-11.

Percentage of Patients with CDI Prior Room Occupancy Risk Hazard Ratio 2.35 p=0.01 Prior Room Occupant Shaughnessy et al. Infect Control Hosp Epidemiol. 2011;32:201-206

Role of the Environment in Disease Transmission Bleach intervention period Mayfield et al. Clin Infect Dis 2000;31:995-1000.

Percentage reduction in frequency of swabs contaminated onventional Terminal Cleaning/Disinfection 100 90 80 70 60 50 40 30 20 10 0

Centers for Medicare Medicaid (CMS) Condition of participation: Infection Control The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigations of infections and communicable diseases.

The Joint Commission Elements of Performance for Standard IC.02.02.01. EP1. The hospital implements infection prevention and control activities when doing the following: Cleaning and performing low-level disinfections of medical equipment, devices and supplies.

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems During your hospital stay, how often were your room and bathroom kept clean? Patient survey tool Measures patients perceptions of their hospital experience Publically reported Linked to Value-Based Purchasing Involves clinical and nonclinical personnel

Bundle for Success Develop policies and procedures Select cleaning products Determine product application Educate personnel Monitor performance Provide feedback Calfee DP et al. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S62

Policies and Procedures Delineate responsibilities What to Clean When to Clean Who s to Clean

Policies and Procedures List the processes needed Daily versus terminal cleaning Category of worker responsible Environmental services or nursing Items to be cleaned Detailed list of all items to be cleaned Products to be used Disinfectant type Manufacturer s recommendations Comments as required Requirements for C. difficile, norovirus, outbreak situations Dumigan DG et al. Am J Infect Control. 2010;38:387

Low Level Disinfection Process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects Factors that affect efficacy include: Prior cleaning Organic and inorganic load present Type and level of microbial contamination Concentration and exposure time of germicide Physical nature of item Presence of biofilm Temperature and ph of the environment

Select Disinfection Products Disinfectant Concentration Contact time Application

Desired Disinfectant Characteristics Function Broad spectrum antimicrobial efficacy Short contact time Good cleaner Compatible with materials Non-corrosive Long shelf life Safety Low toxicity to humans Non-allergenic and nonsensitizing Non-hormone disrupting Environmentally sound Low Volatile Organic Compounds (VOC) Safe to transport Safe and easy to store

Available Products Disinfectant Agent Use Concentration Ethyl or isopropyl alcohol 70% - 90% Bleach Phenolic Iodophor Quaternary ammonium compound 100 ppm to 1000 ppm UD UD UD Improved hydrogen peroxide 0.5%, 1.4% UD=Manufacturer s recommended use dilution http://www.cdc.gov/hicpac/disinfection_sterilization/acknowledg.html

New Antimicrobial Products Copper Silver Organosilane Electrochemically activated Saline Light activated disinfection Liquid glass Sharklet pattern

Product Application Cotton cloth, disposable wipe, microfiber Laundering Cost Sufficient wetness to achieve contact time Size of wipe Durable- will not easily tear or fall apart

Practice Not Product

Transfer of C. difficile Spores from Wipes Cadnum JL et al. Infect Control Hosp Epidemiol. 2013;34:441-2

No Double Dipping! Refillable cleaning bucket Bedrail cultures Before cleaning After cleaning Boyce et al. SHEA 2011 Abstract 113 Kampf et al. BMC Infect Dis 2014, 14;37

Educate What items are to be cleaned Which disinfectant to use What concentration to be used What contact times are recommended Right techniques Order in which to clean items How often to change cleaning cloths or mop heads or disposable wipes Personal protective equipment Importance to infection prevention Role of the environment in disease transmission Team effort

Educate, Observe, and Supervise Guerrero D et al. Decennial 2010, Abstract 60

Challenges in Sustaining Your Gains Variation in cleaning practices Technique Time Confusion on who cleans what Housekeeping Nursing What products are to be used Bleach versus quaternary ammonium compound

Median RLU Readings for Five High-Touch Surfaces Cleaned by Housekeepers A-D 350 300 250 200 150 100 50 0 Bedside Rail Overbed Table TV Remote Bathroom grab bar Toilet Seat A B C D Boyce JM et al. Infect Control Hosp Epidemiol. 2010;31:99-101

Centers for Medicare Medicaid (CMS) Condition of participation: Infection Control All areas of the hospital must be clean and sanitary. The infection prevention and control program must include appropriate monitoring of housekeeping, maintenance (including repair, renovation and construction activities), and other activities to ensure that the hospital maintains a sanitary environment

Monitoring Cleaning Practices Visual inspection Aerobic colony counts Fluorescent marker system ATP bioluminescence assays

Visual Inspection of Surfaces Simple, can be conducted in any facility Usually performed by housekeeping managers Assess surfaces to detect visible dirt/stains Surfaces that appeared clean by visual inspection often failed to pass criteria for cleanliness when tested by objective measures: aerobic colony counts or ATP bioluminescence Griffith CJ et al. J Hosp Infect 2000;45:19 Cooper RA et al. AJIC 2007;35:338

Aerobic Colony Counts Methods of culturing environmental surfaces Moistened swab inoculated onto agar Contact agar plates (Rodac) No standard methods for how to obtain and to process specimens for aerobic colony counts No accepted criteria for defining a surface as clean by using aerobic colony counts Sehulster L et al. MMWR Recomm Rep 2003;52(RR-10):1 Dancer SJ J Hosp Infect 2004;56:10

Fluorescent Marker Systems Surfaces are marked covertly before cleaning Surfaces are checked with a UV light to see if surfaces have been wiped after cleaning Results determine if surface has been wiped or not Results are qualitative

Adenosine Triphosphate (ATP) Bioluminescence Assay ATP swabs are used to surface sample Swab place in reaction tube and gently shaken Place swab in luminometer Results displayed as relative light units (RLUs) Must determine the cut-off to define clean

Advantages and Disadvantages of Methods for Assessing Cleaning Practices Method Advantages Disadvantages Visual inspection Simple Not reliable measure of cleanliness Aerobic colony counts Relatively simple Can detect presence of pathogens More expensive Results not available for 48 hrs later Fluorescent marker system Inexpensive Minimal equipment needed Can improve practices Must mark surfaces before cleaning and check them after cleaning ATP bioluminescence assay systems Provides quantitative measure of cleanliness Quick results Can improve practices More expensive Requires special equipment

Failure analysis in the identification of synergies between cleaning monitoring methods Greg S. Whiteley, Chris Derry, Trevor Glasbey. Am J Infect Control, Volume 43, Issue 2, 2015, 147-153

Scatterplot of ATP & ACC (max 220) log values (After cleaning only)

Monitoring Survey Results 14 4 22 Adenosine triphosphate (ATP) Fluorescent products 33 Observation of room cleaning practices None 64 Other answers 2013 Clostridium difficile infection (CDI) Pace of Progress Survey. of an online poll of 1,087 infection preventionists. APIC. March 2013

Monitoring and Feedback of Cleaning Practices Several studies have shown an improvement in cleaning practices Carling PC et al. Clin Infect Dis 2006;42:385-8 Carling PC et al. Infect Control Hosp Epidemiol 2008;29:1035-41 Boyce JM et al. Infect Control Hosp Epidemiol 2009;30:678-84 Carling PC et al. Crit Care Med 2010;38:1054-9 Traijtman AN et. Al. J Hosp Infect 2013;84:166-72 Alfa MJ et al. Am J Infect Control 2015;43:141-6 Rupp ME et al. Infect Control Hosp Epidemiol 2014;35:721-723 Rupp ME et al. Infect Control Hosp Epidemiol 2014;35:866-868 Ramphal L. Bayl Univ Med Cent. 2104;27:88-91

Median Relative Light Unit Readings, After Daily Cleaning, Phases I and II P <.001 < 0.001.02.002.87 Boyce JM et al. ICHE 2009;30:678

Is it Clean Enough? If given a choice between improving infection control by changing human behavior or new technology, go with new technology every time. Robert Weinstein, MD

Published Papers on No Touch Disinfection Otter JA. Decontamination in Hospitals and Healthcare, Chapter: A guide to 'no-touch' automated room disinfection systems, Publisher: Woodhead Publishing, Editors: Walker JT

Adenosine Triphosphate (ATP) Readings from 5 Sites Sampled from 101 Portable Medical Units and the percentage of readings <250 RLU Site Sampled Median RLU (Range) Percent <250 RLU value Control buttons (n = 58) 86 (14-1, 532) 76 Thermometer (n = 44) 346 (23-8, 340) 39 Blood pressure cuff (n = 79) 477 (42-31, 877 24 Machine handle (n = 54) 480 (42-31, 877) 24 Pulse oximeter (n = 65) 1,208 (59-27, 297) 22 Aerobic colony counts for the 5 sites sampled from 26 portable medical BP units Site Sampled Control buttons (n = 21) 2 (0-226) Thermometer (n = 16) 3 (0-22) Blood pressure cuff (n = 23 Machine handle (n = 19) Median ACC (Range) 2 (0-TNTC) 5 (0-TNTC) Pulse oximeter (n = 21) 53 (0-813) Havill NL, Am J Infect Control. 2011; 39:602-4

Cleaning efficacy Kiedrowski LM et al, Am J Infect Control. 2013;41(11), 1136-7.

Cleaning efficacy Howell V. et al. J Hosp Infect (in press)

Questions?