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Is Your Facility Clean? DAZO Knows. Sandra Von Behren. Objectives. Discuss the role of the environment in the transmission of healthcare-associated infections (HAIs) and multi-drug resistant organisms (MDROs) Identify available methods to evaluate environmental cleanliness

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is your facility clean dazo knows

Is Your Facility Clean?DAZO Knows

Sandra Von Behren

TSICP

objectives
Objectives
  • Discuss the role of the environment in the transmission of healthcare-associated infections (HAIs) and multi-drug resistant organisms (MDROs)
  • Identify available methods to evaluate environmental cleanliness
  • Discuss strategies to improve environmental cleaning and decrease the risk of MDRO and HAI transmission

TSICP

philip c carling md
Philip C. Carling, MD
  • Boston University School of Medicine
  • Department of Epidemiology,Carney Hospital
  • Boston, MA

TSICP

the environment as a source of pathogens
The Environment as a Source of Pathogens
  • S. aureus
    • Dancer et al; JHI 2006; 62: 200-206
  • MRSA
    • Boyce et al, ICHE 1997; 18:622-627
  • VRE
    • Bhalla et al, ICHE 2004; 25: 164-167
    • Hayden, et al, ICHE 2008; 29: 149-154

TSICP

environmental contamination is there a link to hai acqusition
Environmental Contamination: Is There A Link to HAI Acqusition?

Patients admitted to rooms previously occupied by patients with MRSA, VRE, Acinetobacter baumanii are at risk of acquiring organisms from the environment

Huang, et al; Arch Intern Med 2006; 166: 1945-1951

Hardy , et al; ICHE 2006; 27: 127-132

Sexton et al; JHI 2006; 62: 187-194

Martinez, et al; Arch Intern Med 2003; 163: 1905-1912

TSICP

environmental contamination with antimicrobial resistant organisms mdros
Environmental Contamination with Antimicrobial Resistant Organisms (MDROs)

Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

environmental contamination with antimicrobial resistant organisms mdros7
Environmental Contamination with Antimicrobial Resistant Organisms (MDROs)

39 % of positive cultures from staff only touched objects were different from those for which the patient was being isolated

Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

slide8

Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour

Adapted from - Hardy KJ et.al J Hosp. Infections 66,360 August 2007

c difficile environmental contamination
C. Difficile Environmental Contamination

Mutters R, etal. J Hosp Infect. 2009; 71: 43-48

survival of pathogens on environmental surfaces
Survival of Pathogens on Environmental Surfaces

C. difficile > 5 months

Staphylococci 7 months VRE 4 months Acinetobacter 5 months

Norovirus 3 weeks Adenovirus 3 months Rotavirus 3 months SARS, HIV etc. days to week

c difficile transmission from prior room occupants
C. difficile Transmission From Prior Room Occupants

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

c difficile transmission to prior room occupants
C. difficile Transmission to Prior Room Occupants

110% Increased risk

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

slide14

HCW

HANDS

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

slide15

HCW

HANDS

ISOLATION

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

slide16

HAND HYGENE

HCW

HANDS

ISOLATION

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

slide17

HAND HYGENE

HCW

HANDS

ISOLATION

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

ENVIRONMENTAL SURFACES

slide18

HAND HYGENE

HCW

HANDS

ISOLATION

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

ENVIRONMENTAL SURFACES

slide19

HAND HYGENE

HCW

HANDS

ISOLATION

ANTIBIOTIC RESISTANT PATHOGENS

ON / IN

PATIENTS

SUSCEPTABLE

PATIENTS

ENVIRONMENTAL SURFACES

DISINFECTION CLEANING

prevent transmission hand hygiene
Prevent Transmission:Hand Hygiene
  • Many facilities have had significant improvements
  • Microbial resurgence is rapid following HH
  • Logistical limitations in a complex environment

TSICP

hh in complex intense environments is very difficult
HH in Complex Intense Environments is Very Difficult

30 to 40 HH “Moments” per Hour during direct patient care

isolation
Isolation
  • Difficult to implement and maintain
  • When to Begin—When to stop
  • Unintended consequences

TSICP

slide24
Our review of the literature demonstrates that contact precautions have unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of contact precautions are urgently needed.

Am J Infect Control. 2009 (May); 37: 85-91

what can we do
What can we do??

Improve effectiveness of environmental cleaning/

disinfection patient environment

how can we evaluate environmental cleaning
How Can We Evaluate Environmental Cleaning
  • Direct observation
  • Culture the environment
  • ATP bioluminescence Tool
  • Fluorescent marking tool

TSICP

atp bioluminescence
ATP bioluminescence

Swab surface luciferase tagging of ATP Hand held luminometer

Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.

atp bioluminescence testing in healthcare settings
ATP Bioluminescence Testing in Healthcare Settings

Potential usefulness:

Has been used as a surrogate for environmental culturing

Provides an estimate of cleanliness

Can rapidly define how clean an object is…. but non-microbial ATP is also evaluated

Standards to optimize predictive values are still being evaluated

Can be used to do one-on-one education of ES staff

atp bioluminescence testing in healthcare settings29
ATP Bioluminescence Testing in Healthcare Settings

Potential limitations:

Secondary cleaning of the site is required to remove disinfectant induced signal decay or enhancement.

Involvement of the ES staff is implicit since evaluation must be done within minutes of cleaning.

Pre-intervention evaluation of disinfection cleaning is difficult without inducing a Hawthorne effect

Results are individual ES staff / time specific.

Many manufacturers of luminometers and ATP swabs makes interinstitutional standardization difficult

goal of the project

GOAL OF THE PROJECT

To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

the targeting solution
The Targeting Solution
  • A mixture of several glues, soaps and a targeting dye which:
    • Dries rapidly
    • Remains stable
    • Easily removed with light abrasion and damp cloth
    • Inconspicuous
slide39

Terminal cleaning after 1 or 2 patient cycles

Cleaned, empty

room

identified

Room marked

Room evaluated

Phase I: Covert Baseline Environmental Cleaning Evaluation

Terminal cleaning after 1 or 2 patient cycles

Cleaned, empty

room

identified

Room marked

Room evaluated

Phase II: A. Programmatic Analysis

B. Educational Interventions – ES staff

Phase III: Re-evaluation of Cleaning and feedback to ES

preliminary results three hospitals
Preliminary Results – Three Hospitals

Clinical Infectious Diseases – February 2006

slide41

The Healthcare Environmental Hygiene Study Group

On the basis of our preliminary results and presentations at SHEA, APIC and ICAAC conferences we have gathered together a group of hospitals to further evaluate the tool and process improvement programs

slide44

Baseline Environmental Evaluation of

36 Acute Care Hospitals

Mean = 48.5 %

Hospitals

(20,056 Objects)

% of Objects Cleaned

proportion of objects cleaned as part of terminal room cleaning in 20 acute care hospitals
PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS

%

slide46

Terminal Room Cleaning Project – Three Programmatic Responses

17 HOSPITALS

10 HOSPITALS

8 HOSPITALS

slide47

Hospitals Environmental Hygiene Study Group36 Hospital Results

% of Objects Cleaned

PRE INTERVENTION

POST INTERVENTION

Resource Neutral

P = <.0001

slide48

Specific Opportunities for Improvement

  • TERMINAL ROOM CLEANING
  • INFECTION PREVENTION
  • TARGETS
        • Sink and Faucets
        • Toilet Surfaces
        • Toilet Flush Handle
        • Bedpan Cleaner
        • Toilet Area Handholds
        • Toilet Area Door Knobs or
        • Push Plates
        • Bedside Table
        • Tray Table
        • Patient Chair
        • Side Rails
        • Room Door Knobs
        • Call Box
        • Telephone
        • Bathroom Light Switches
focus group
Focus Group
  • Held 4 meetings with Environmental Services (EVS) staff on different shifts
    • 5-6 staff members in each session
    • Met for 4 hours
    • No EVS supervisors present
    • Meal provided

TSICP

focus group questions
Focus Group Questions
  • What recommendations do you have to improve cleaning outcomes?
  • What barriers do you see that would prevent implementation of these recommendations?

TSICP

problems identified
Problems Identified
  • Staffing not always adjusted to busiest times
  • Pressure from nursing staff to “get it done”
  • Supervisors not visible
  • Staff on evening shift “on call” from one end of hospital to the other

TSICP

recommendations
Recommendations
  • More “on the spot” feedback from supervisors
  • Help from supervisors to prioritize work
  • Better communication with nursing
  • Consistency unit to unit
  • Maintain level of cleaning done when TJC is expected
  • Have a quality control officer
  • Use Dazo as follow-up to classroom orientation
  • Evaluation of work efficiencies (Organizational Improvement)

TSICP

icu project
ICU Project
  • Daily Clean of Isolation Rooms
  • Marked room and read in or 2 days

TSICP

possible interventions
Possible Interventions?
  • How can we improve on daily disinfection cleanings?
  • Who is responsible for each item?

-Siderail bed control -Table/counter/workspace

-Call button -Computer keyboard

-Tray table -Storage drawer handle

-Monitor control -Room light switch

-Vent control - Room door handles

-Commode -IV pump

-Sink

item responsibility
Environmental Services:

Tray table

Light switch

Room door handles

Sink

Work surface

Cabinet handles

Call button

In-room commode

ICU Nursing:

Keyboards

Side rails

IV pumps

Monitor control panel

Respiratory Therapists:

Ventilator Control Panel

Item Responsibility
  • Re-evaluation will take place in 3-4 weeks
brigham woman s icu study57
Brigham & Woman’s ICU Study

Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009

Datta R, Platt R, Kleinman K, Huang SS

brigham woman s icu study58
Brigham & Woman’s ICU Study

Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009

Datta R, Platt R, Kleinman K, Huang SS

“For both MRSA and VRE, absolute risk appeared diminished during the intervention regardless of prior occupant status”

conclusions
Conclusions
  • It is likely that surfaces in the Patient Zone are of relevance in the transmission of Healthcare Associated Pathogens.
  • While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.
references
References
  • Hayden MK, Bonten JM, Blom DW, Lyle EA. Reduction in acquisition of Vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis 2006; 42:1552-1560.
  • Eckstein BC, Adams DA, et al. Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007 Jun 21;7:61
  • Dancer SJ, White L, Robertson C. Monitoring environmental cleanliness on two surgical wards. Int J Env Health Res 2008; 18: 357-364
  • 195.92.246.148/knowledge_network/documents/Bioluminescence_20070620104921.pdf
  • Carling PC, Parry M, Rupp, M, Po JL,DickB, Von Beheren S. for the Healthcare Environmental Hygiene Study Group. Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:11,035-1041