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Are Shiny Floor Enough? Environmental Hygiene Challenges in Hospitals Philip C. Carling, M.D. Boston University School of Medicine. San Francisco Bay Area APIC Spring Meeting Walnut Creek, California May 14, 2008. Grant Support - None. Disclosures - None. Contaminated Surfaces .

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slide1

Are Shiny Floor Enough?Environmental Hygiene Challengesin HospitalsPhilip C. Carling, M.D.Boston University School of Medicine

San Francisco Bay Area APIC Spring Meeting

Walnut Creek, California

May 14, 2008

Grant Support - None

Disclosures - None

contaminated surfaces
Contaminated Surfaces

VRE MRSA C. difficile

Bed Rails +++++++ + +++

Bed Table ++++++ +

Door Knobs ++ ++ +

Doors +++ +

Call Button +++ + ++

Chair ++ + ++

Tray Table +++ ++

Toilet Surface + ++++

Sink Surface + + +++

Bedpan Cleaner +

slide4

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

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

C. Difficiele – > 5 months MRSA – 90 to > 236 d. VRE – 7 to 120 d. (Median = 60 d.) A. baumanii – Mean = 9 d.

Rhinoviruses – Several hours Hepatitis A – > 4 hours Norovirus - Weeks

how well is environmental cleaning being done in hospitals
How well is Environmental Cleaning being done in hospitals ?

Is Environmental Cleaning in hospitals important?

A.

Yes

How Effective are the Environmental Disinfectants used in hospitals ?

B.

C.

how well does environmental disinfecting work
How Well Does Environmental Disinfecting Work ?
  • Phenolic Compounds
  • Quartinary Amonium Compounds
  • Chloride Disinfectants
  • Formaldehyde

Kill a wide range of microbial pathogens

Work Rapidly

Work effectively in clinical settings

ALL

slide9
CDC

Monitor (i.e., supervise and inspect) cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and likely to be touched by the patient and health care Professionals (e.g. bedrails, carts, bedside commodes, doorknobs, faucet handles). Category 1B.

Management of MDROs in Healthcare Settings – October 2006 V.B.8.b.

slide10
IHI

“Hospitals should use immediate feedback mechanisms to assess cleaning and reinforce proper technique”

5 Million Lives Campaign – Guide to Significantly Reducing MRSA Infections

December 2006

482 42 condition of participation infection control interpretive guidelines 482 42 november 21 2007

CMS

The hospital must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases…The infection prevention and control program must include appropriate monitoring of housekeeping… activities to ensure that the hospital maintains a sanitary environment.

§482.42 Condition of Participation: Infection Control

Interpretive Guidelines §482.42

November 21, 2007

482 42 condition of participation infection control interpretive guidelines 482 42 november 21 200712

CMS

A hospital with a comprehensive hospital-wide infection control program should have and implement ….provisions to monitor compliance with all policies, procedures and protocols…

§482.42 Condition of Participation: Infection Control

Interpretive Guidelines §482.42

November 21, 2007

how well is environmental cleaning being done in hospitals13
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Culture the environment

ATP bioluminescence Tool

Fluorescent marking tool

how well is environmental cleaning being done in hospitals14
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Hayden – only study

Education and feedback

Thoroughness of cleaning 48% 83%

Culture the environment

ATP bioluminescence Tool

Fluorescent marking tool

how well is environmental cleaning being done in hospitals15
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Culture the environment

Many Studies have evaluated environmental contamination in occupied rooms

Only two studies have evaluated the impact of

routine terminal cleaning on HAI pathogens

ATP bioluminescence Tool

Fluorescent marking tool

a microbiologic evaluation of patient room contamination and disinfection
A Microbiologic Evaluation of Patient Room Contamination and Disinfection

% POSITIVE

Bhalla etal. ICHE 2004

slide17

June 2007

Methods:

Culture based evaluation - Pre-intervention;

- after routine terminal cleaning;

- after terminal cleaning by the research staff;

- following education of the ES staff and administrative interventions

percentage of vre positive cultures n 17 rooms

Bedrail

Bedside table

Phone

Call button

Toilet

Door handle

80

70

60

50

40

Percent positive

30

20

10

0

After

housekeeping

cleaning

After

disinfection by

research team*

Before cleaning

Percentage of VRE-positive cultures n=17 rooms

*Similar results found after ES cleaning following interventions

Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.

percentage of c difficile positive cultures n 9 rooms

Bedrail

Bedside table

Phone

Call button

Toilet

Door handle

80

70

60

50

40

Percent positive

30

20

10

0

After

housekeeping

cleaning

After

disinfection by

research team*

Before cleaning

Percentage of C. difficile-positive cultures n=9 rooms

*Similar results found after ES cleaning following interventions

Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.

how well is environmental cleaning being done in hospitals20
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Culture the environment

Many Studies have evaluated environmental contamination in occupied rooms

Only two studies have evaluated the impact of routine terminal cleaning on HAI pathogens

Conclusion: Environmental Culturing as a research tool is very valuable but cost will limit routine use in hospitals

how well is environmental cleaning being done in hospitals21
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Culture the environment

ATP bioluminescence Tool

Fluorescent marking tool

surface evaluation using atp bioluminescence
Surface evaluation using ATP bioluminescence

Swab surface luciferace 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.

how well is environmental cleaning being done in hospitals23
How well is Environmental Cleaning being done in hospitals ?

Four Methods of evaluation:

Direct observation

Culture the environment

ATP bioluminescence Tool

Conclusion: May be useful for one on one teaching but does not evaluate programmatic process

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

Environmentally stable

Readily wetted by spray disinfectants

Easily removed with light abrasion

Inconspicuous

targeting patient rooms
Targeting Patient Rooms

Objects were chosen by considering sites

A. A patient was most likely to contaminate

and

B. A care givers may touch with their hands

Up to 14 objects marked in each room after terminal cleaning

Objects were evaluated after one to two patients had cycled through the room to see if targets had been removed by discharge cleaning activities

environmental cleaning evaluation in three hospitals

Environmental Cleaning Evaluation in Three hospitals

- A confidential evaluation without Environmental Services awareness was implemented

- About 50 patient rooms / Hospital

- Up to 14 objects marked when the room was empty

- Evaluated after patient had cycled through the room and it had been terminally cleaned

preliminary results three hospitals
Preliminary Results – Three Hospitals

Clinical Infectious Diseases – February 2006

slide29

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

goals of the multi institutional terminal room cleaning project
Goals of the Multi-institutional Terminal Room Cleaning Project

To determine if:

  • The targeting methodology is appropriately user friendly;
  • The thoroughness of cleaning at other institutions is similar or different from what we had found to date;
  • Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time).
healthcare environmental hygiene study group
Altru Hospital Grand Forks, ND

Avera McKennan MC Sioux Falls, SD

B I Deaconess MC Boston, MA

Bay Park Hospital Oregon, OH

Boston MC Boston, MA

Brigham & Women’s Boston, MA

Carney Hospital Boston, MA

Defiance Reg. MC Defiance, OH

Flower Hospital Sylvania, OH

Fostoria Hospital Fostoria, OH

Kaiser Med C Sacramento, CA

Kaiser Santa Rosa Santa Rosa, CA

Kaiser Sunnyside Clackamas, OR

Lahey Clinic Burlington, MA

Memorial Hosp of RI Pawtucket. RI

Mercy Med Center Merced, CA

Miriam Hospital Providence, RI

Methodist Hospital Henderson, KY

L. Morse Hosp Natick, MA

Nebraska Medical Center Omaha, NE

Oregon HS Center Portland, OR

Provident ST Vincent Portland, OR

Pullman Regional Hosp. Pullman, WA

Quincy Medical Center Quincy, MA

Rhode Island Hosp. Providence, RI

Saint Luke’s Hospital Bethlehem, PA

St Vincent Healthcare Billings, MT

Shands – AGH Gainesville, FL

Sharp Memorial H San Diego, CA

Somerville Hospital Somerville, MA

South County Hosp. Wakefield, RI

Stamford Hospital Stamford, CT

Toledo Hospital Toledo, OH

U. Iowa Hospitals Iowa City, IA

Union Memorial Hosp Baltimore, MD

Washington H Center Washington, DC

Westerly Hospital Westerly, RI

Whidden Mem. Hosp. Everett, MA

Healthcare Environmental Hygiene Study Group
hospital demographics
Hospital Demographics

All Acute Care Hospitals

Size – 25 to 754 Beds (Mean = 243)

Medicare Case Mix Index – 1.41 (Average)

Rooms evaluated – 28 – 69 (Mean = 43)

All high touch objects evaluated by ICP volunteers

the program

The Program

Phase I

Covert Baseline Environmental Cleaning Evaluation

(The same as Previously described)

slide35

Baseline Environmental Evaluation of 3 Acute Care Hospitals

Mean = 47.7 %

Hospitals

% of Objects Cleaned

slide36

Baseline Environmental Evaluation of 20 Acute Care Hospitals

Mean = 48.3 %

Hospitals

% of Objects Cleaned

ICHE January 2008

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

%

proportion of objects cleaned as part of terminal room cleaning in 20 acute care hospitals38
PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS

%

the program39
The Program

Phase I – Covert Baseline Environmental Evaluation

Phase II

A. Educational Interventions – ES Staff

B. Feedback to the ES – Staff

the program40
The Program

Phase I – Covert Baseline Environmental Evaluation

Phase II

A. Educational Interventions – ES Staff

B. Feedback to the ES – Staff

(repeated as needed)

basis for sub optimal improvement
Basis for Sub-optimal Improvement
  • Manpower / Staffing Issues:

Unequal distribution of work loads

Unrealistic ES staff expectations

Shorter LOS – Same ES manpower

Escalating “Isolation Cleaning”

  • ES Management Issues

Resistance to new ideas

“If the floors shine…What’s the problem”

“Who died and left the ICPs in charge of ES”

  • Systems Problems – Previously Hidden

Identifying Opportunities to Enhance Environmental Cleaning in Twenty-three Acute Care HospitalsCarling P, Parry MF, Von Beheren S, for the HCEHSG ICHE 2008; 29:1-7

implementation challenges
Implementation Challenges
  • >30 Additional hospitals wanted to

participate but the ICPs were too

overwhelmed with other responsibilities

  • 7 Hospitals withdrew:

4 Administrative reprioritization of ICP

3 Fear the hospital would be identified

  • ASHES Conference – September 2006
were the goals realized
Were The Goals Realized ?

To determine if:

  • The targeting methodology is appropriately user friendly; YES – Easy on – Easy off
  • The thoroughness of cleaning at other institutions is similar or different from what we had found to date; Overall quite similar
  • Cleaning can be improved using focused educational interventions and feedback to the ES staff using limited resources (time).

YES….but in some hospitals it takes more work

fluorescent marking tool conclusions
Fluorescent marking toolConclusions

Advantages:

Simple to use highly objective process improvement tool

Applicable to many healthcare settings / processes

Disadvantages:

Evaluates process alone

Does notevaluate how well an individual object is cleaned

studies in which have evaluated the relevance and epidemiology of environmental haps

Studies in which have evaluated the relevance and epidemiology of environmental HAPs

healthcare environmental hygiene study group current projects
Healthcare Environmental Hygiene Study GroupCurrent Projects
  • Hospital Post Discharge Cleaning Project – Beta sites
  • OR Terminal Cleaning Project – 16 sites
  • NICU Discharge Cleaning Project – 15 sites
  • ICU daily Cleaning Project – 12 sites
  • Skilled Nursing Facility Daily Cleaning Project – 5 Sites
  • Iowa Statewide MRSA Control Project – About 100 sites
  • Chemotherapy Suite Daily Cleaning Project – 10 sites
  • Canadian Consortium – 6 Major Medical Centers
thanks for inviting me to your meeting

Thanks for inviting me to your meeting!!

Philip C. Carling, M.D.

pcarling@cchcs.org