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Environmental Disinfection ~ A Review of Hydrogen Peroxide Vapor Technology Lessons from a Community Hospital Nancy Iversen, RN, CIC Director, Patient Safety & Infection Control Billings Clinic [email protected] 406-657-4823. Not-for-profit, community owned and governed

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Environmental Disinfection ~A Review of Hydrogen Peroxide Vapor Technology Lessons from a Community Hospital Nancy Iversen, RN, CIC Director, Patient Safety & Infection ControlBillings [email protected] 406-657-4823


  • Not-for-profit, community owned and governed

  • Multi-specialty Physician Group Practice

  • 3,750 employees

  • 260 employed physicians representing 50 specialties

  • 285-bed hospital, 90-bed LTCF

  • 7 regional branch clinic locations

  • Multi-state management affiliations and support services

  • Member of Mayo Clinic Care Network


Learner objectives

Describe two unique characteristics, changing epidemiology, and environmental persistence of Clostridium difficile bacteria

Discuss two strategies that prevent the transmission of healthcare-associated Clostridium difficile and other pathogens

Describe the current environmental disinfection strategies and application of hydrogen peroxide vapor ~ BIOQUELL

Discuss advantages and disadvantages of hydrogen peroxide vapor disinfection technology

Learner Objectives


Examples of the unseen what you learn will creep you out
Examples of The Unseen and environmental persistence of What You Learn Will Creep You Out!

The Dust Mite

Photo courtesy of Janet Stout, PhD, Special Pathogens Lab


About unseen dust mites
About and environmental persistence of Unseen Dust Mites

  • A typical mattress may have anywhere from 100,000 to 10 million mites inside.

  • 10% of the weight of a two-year old pillow can be composed of dead mites and their droppings.

Photo courtesy of Janet Stout, PhD, Special Pathogens Lab


Background
Background and environmental persistence of

Environmental contamination contributes to transmission of healthcare-associated pathogens1

There is increased risk of acquisition of multidrug-resistant organisms in rooms where the previous occupant was colonized or infected with the organism2,3,

1. Weber D et el. Am J Infect Control 2010;38:25-33

2. Drees M et al. Clin Infect Dis 2008;46:678-85

3. Datta M et al. Arch Intern Med 2011;171:491-494

4. Nseir S et al. Clin Microbiol Infect 2010;Nov 4


Background1
Background and environmental persistence of

Standard methods of cleaning and disinfecting surfaces in hospitalized patient’s rooms are sub-optimal1,2

Novel technologies used to decontaminate patient rooms include3,4

Hydrogen Peroxide Vapor (BioQuell)

Ultraviolet Light (UV-C Radiation)

1. Boyce JM et al. Infect Control Hosp Epidemiol 2010;31:99-101

2. Carling PC. J Hosp Infect 2008;68:273-274

3. Nerandzic MM et al. BMC Infect Dis 2010;10:197

4. Boyce JM et al. Infect Control Hosp Epidemiol 2008;29:723-729

5. Havill NL. Infect Control Hosp Epidemiol 2012; 33(5):000-000


Contaminated surfaces can contribute to transmission

Contaminated environmental surfaces can contribute to transmission of pathogens

By serving as a source from which healthcare workers contaminate their hands or gloves

Contaminated medical equipment that comes into direct contact with the patient can serve as a source of transmission

Contaminated Surfaces Can Contribute to transmission

Boyce JM et al. Infection Control Hosp Epidemiology 1997; 28:1142

Bhalla A et al. Infection Control Hosp Epidemiology 2004; 25:164

Hayden MK et al. Infection Control Hosp Epidemiology 2008; 29:149

Passaretti CL, Clin Infect Dis; 2013; 56(1): 27-35


Survival of Pathogens in the Environment transmission of pathogens

  • Pathogens that survive well in the environment include:

  • Clostridium difficile

  • MRSA

  • VRE

  • Acinetobacter

  • Norovirus

Hota B., et al. Clin Infect Dis 2004; 39:1182

Kramer A., et al. BMC Infect Dis 2006; 6:130


Cdi epidemiology issues

Rates Increasing world wide and in US transmission of pathogens

Outpacing MRSA Healthcare-associated Infections

Common epidemic C. difficile strain continues to be reported from hospitals in expanding list of states

More severe disease with

higher mortality – 6.9% (30 days), 16.7% at one year

higher readmissions

higher rates of colectomy in the elderly continues

Point-source outbreaks well described

Environment plays a role in transmission to other patients

Environmental survival of C. difficile spores is 5 months

CDI Epidemiology / Issues


Problem / Opportunity transmission of pathogens

Clostridium difficile Infection (CDI)

2007 – December 31, 2014

Cost: $7179 / case (Scott, DR, Direct Medical Costs of HAI in US Hospitals, CDC, March 2009)

Published incidence rate: 3.8-9.5 cases per 10,000 patient days

(SHEA / IDSA Practice Guideline 2010).


Vancomycin Resistant Enterococcus (VRE) transmission of pathogens

1997 – March 31, 2011

  • 2010 VRE Outbreak Investigation

  • 6 new HA VRE cases June 2010 – October 2010

    • (no HAI VRE cases Jan – June ’10)

  • 3 HA colonizations (transmissions)

  • 3 HA infections

  • PFGE Typing conducted suggested cross-transmission


Billings clinic hospital study august 2010

Terminal cleaning after 2 patient cycles transmission of pathogens

Cleaned & empty room identified

Rooms marked with fluorescent marker DAZO, (Ecolab)

Room evaluated

Billings Clinic Hospital Study (August 2010)

Phase 1: Baseline Environmental Cleaning Evaluation

Study Design:

  • Marked 120 high-touch surfaces in 10 Patient Rooms

    • IPS (2 rooms, N & S)

    • IPM (2 rooms, N & S)

    • ICC (1 room)

    • ATU (1 room)

    • ICU (1 room)

    • ICC (1 room)

    • SSU (1 room)

    • ED (2 rooms)


Study results high touch surfaces cleaning study hospital baseline august 2010
Study Results transmission of pathogensHigh Touch Surfaces Cleaning Study – HospitalBaseline ~ August 2010

Ongoing Performance ~ January - December 2013


Footboard Control Panel transmission of pathogens

After Cleaning ~ Fluorescent marks remain


Computer Keyboard transmission of pathogens

After Cleaning ~ Fluorescent marks remain


High touch environmental surfaces cleaning verification
High Touch Environmental Surfaces transmission of pathogensCleaning Verification

January – April 15, 2014

98.0% (1505/1536)

Currently, DAZO fluorescent marking system is being used for EVS training and

patient room disinfection verification. Process improvement ongoing.


High touch environmental surfaces cleaning verification1
High Touch Environmental Surfaces transmission of pathogensCleaning Verification


Comparison of Disinfection Technology transmission of pathogens


Comparison of Disinfection Technology transmission of pathogens


Bacterial growth before after decontamination hpv vs uv c
Bacterial Growth Before & after Decontamination ~ HPV vs. UV-C

68

70

N = 75

33

Number of positive samples

5

HPV vs. UVC (p <0.0001)

Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol 2012;33(5):000-000


Bacterial growth after decontamination 5 surfaces using hpv vs uv c
Bacterial Growth After Decontamination UV-C 5 Surfaces using HPV vs. UV-C

Shadowed

12

10

Non-shadowed

Number of positive samples

5

4

2

2

1

1

1

0

HPV: Shadowed vs. non-shadowed (p =1)

UVC: Shadowed vs. non-shadowed (p <0.0001)

Cultures with no growth before decontamination excluded

Havill NL, Moore BA, Boyce JM, Hosp Infect Control Epidemiol 2012;33(5):000-000


C difficile log reductions achieved
C. UV-Cdifficile Log Reductions Achieved

3.0

2.5

2.2

1.8

1.7

Log reductions

Havill NL, Moore BA, Boyce JM, Infect Control Hosp Epidemiol. 2012;33(5):000-000


Hydrogen peroxide vapor bioquell process evaluation period feb 2011
Hydrogen Peroxide Vapor (Bioquell) Process UV-CEvaluation Period Feb. 2011

Room cleaned of visible soil

Ventilation & doorways sealed

Generator creates HPV from 35% Hydrogen Peroxide

Aeration unit catalytically converts HPV to oxygen and water vapor

Computer allows for process control and auto shut off


BioQuell Q-10 Room Sterilization System UV-C

Hydrogen Peroxide Vapor (HPV)


Biological Indicator ~ Test Organism UV-C

Geobacillus stearothermophilus

  • Purchase HPV 106 BI’s from outside lab

  • Run quarterly testing to verify efficacy

  • Expose 4-5 HPV BI discs to 10 grams Hydrogen Peroxide

  • Incubate at 55-600C for 7 days

  • Chemical indicator pilot

Ongoing verification of 106log reduction


BIOQUELL Unit ~ Vent Sealing Device UV-C

One to three units per room


BioQuell Unit in Use ~ ICU Room 2117 UV-C

10 min. set-up; 90 min. cycle time; 5 min. tear down


BioQuell Trial ~ ICU Room 2117 UV-C

10 min. set-up; 90 min. cycle time; 5 min. tear down

(ICC Room ~ 4466 = 2 hrs, 40 min. / ICU 2114 = 75 min.)



Uv c process
UV-C Process UV-C

Room cleaned of visible soil

UVC device placed in the center of the room

Door closed

UVC (254 nm range) delivers 22,000 uW sec/cm2

Hand held device controls settings monitors the process


Tru-D Unit Setup ~ ICC Room 4465 UV-C

5 min. set-up; 90 min. cycle time; 10 min. tear down


Tru-D Unit In-Use ~ ICU Room 2121 UV-C

12 min. set-up; 54 min. cycle time; 10 min. tear down


Conclusions
Conclusions UV-C

HPV and UV-C significantly reduce bacterial contamination in patient rooms

HPV is significantly more effective than UV-C for the eradication of bacteria, including spores

UV-C is significantly less effective in shadowed areas from the device


Recommendation

Acquire BioQuell Q-10 Unit (HPV) technology for terminal room disinfection

Adopt objective measurement for cleaning & disinfection processes (e.g. fluorescent marker, ATP)

CDC recommendation, CMS requirement

Priority Applications ~ Terminal Disinfection

C. difficile rooms

VRE rooms

IVF Laboratory

Equipment Disinfection ~ create BioQuell Room

Norovirus

Unused supplies in isolation rooms

Recommendation


Current applications

Priority Applications ~ Terminal Disinfection room disinfection

Clostridium difficile rooms (20 minute kill time)

VRE rooms

Norovirus

Emerging Multi-drug Resistant Organisms (MDRO)

ESBL, CRE

Acinetobacter (BIOQUELL kill time 60 minutes)

Other Resistant Gram-negative bacteria

IVF Laboratory in Surgery Center

Disinfection of Equipment / Unused Supplies

Unused medical supplies in isolation rooms

Otter JA, Infect Control HospEpidemiol May 2013, Vol. 34, No.5.

7-9% contamination VRE/MDRO, None of the items were contaminated after HPV (p<.02)

Annual cost of supplies discarded at hospital discharge was $387,055.

Currently run cycles in equipment storage rooms, gait belts.

Current Applications


Bioquell cost per patient room
BIOQUELL Cost Per Patient Room room disinfection

  • $56.00 per 500ml bottle of peroxide

  • 2 – 500ml bottles per room

  • 1 tech at $17.00/hour plus benefits

  • Average time per room start to finish 3.5 hours (set up 30 minutes)

  • Total cost per room = $185.00

  • Updated 2014: $220.00 new larger rooms

    • Room size ranges 40-172 m3


Bioquell 1 year cost
BIOQUELL ~ 1 Year Cost room disinfection

Internally Managed Program

BIOQUELL Managed Program

  • 281 patient rooms

  • 281 rooms at $185 per room

  • $51,985.00

  • $5,000 Annual P.M. and training

  • Total Annual Cost: $56,985.00

  • $13,500/month or

  • Total Annual Cost: $162,000

  • Projected 2014 cost (larger rooms)

  • 25 rooms / month ~ 300 / year

  • $220.00 per room + $5,000 annual P.M.

  • Total Annual Cost: $71,000


Bioquell use summary
BIOQUELL Use Summary room disinfection

  • Began November 1, 2011

  • 793 applications

    • 75% C. difficile rooms

    • 20% cycle cleans

    • 4% other MDRO’s ~ VRE, Norovirus, ESBL

    • 1% other (IVF, equipment rooms)

  • Average cycle time 3.5 - 4 hours, 30 min. set-up

  • Perform initial terminal clean with bleach disinfectant

  • Run BI’s quarterly, evaluating CI’s (12 rooms)


Lessons learned
Lessons Learned room disinfection

Advantages

  • Efficacy

  • Efficacy validated

  • Retain EVS personnel

    • Decontamination Specialists

    • Substantial salary increase

  • Staff acceptance high

    • Gait belts

    • Equipment storage areas

Disadvantages

  • Customer service decline

  • Recent breakdowns

  • Longer room turnover

  • Missed decontaminations

    • High census, velocity

    • Breakdowns


Learner objectives1

Describe two unique characteristics, changing epidemiology, and environmental persistance of Clostridium difficile bacteria

Discuss two strategies that prevent the transmission of healthcare-associated Clostridium difficile and other pathogens

Describe the current environmental disinfection strategies and application of hydrogen peroxide vapor ~ BIOQUELL

Discuss advantages and disadvantages of hydrogen peroxide vapor disinfection technology

Learner Objectives


Questions? and environmental persistance of


Hand hygiene study
Hand Hygiene Study and environmental persistance of


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