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Fundamentals of UV for Hospital Surface Treatment

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Welcome to

Fundamentals of UV for Hospital Surface Treatment

(An Online Continuing Education Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is being offered online and may be completed at any time.

Steps for Successful Course Completion

To earn continuing education credit, the participant must complete the following steps:1. Read the overview and objectives to ensure consistency with your own learning

needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective.

2. Review the content of the activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

© 2015All rights reserved

Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196

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OVERVIEW Healthcare-associated infections (HAIs) can be life threatening and are putting patient lives at risk every day. They are also impacting hospital budgets – in the millions – as new payment penalties and reporting requirements are implemented by the government and private health insurance companies. As a result, many hospital and clinical leaders are looking for tools, such as ultraviolet (UV) treatment devices, that can help reduce HAI-causing pathogens found in the environment.

This continuing education activity will discuss ultraviolet technology, how it can be implemented and discuss the benefits that it can provide from an infection prevention perspective.

LEARNER OBJECTIVES After completing this continuing education activity, the participant should be able to:

1. Describe ultraviolet (UV) light technology and the different types of UV light. 2. Identify the data that supports UV-C device efficacy. 3. Discuss the benefits and limitations of using UV-C devices in healthcare facilities. 4. Discuss UV-C device implementation in a facility. 5. Identify the selection criteria for UV-C technology.

INTENDED AUDIENCE This continuing education activity is intended for perioperative nurses and other health care professionals who want to learn more about infection control through the use of UV-C devices.

CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hours.

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

IACET Pfiedler Enterprises has been accredited as an Accredited Provider by the International Association for Continuing Education and Training (IACET).

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CEU Statements• As an IACET Accredited Provider, Pfiedler Enterprises offers CEUs for its

programs that qualify under the ANSI/IACET Standard. • Pfiedler Enterprises is accredited by IACET to offer 0.2 CEUs for this program.

RELEASE AND ExPIRATION DATE:This continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in October 2015 and can no longer be used after October 2017 without being updated; therefore, this continuing education activity expires October 2017.

DISCLAIMERPfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity

SUPPORTFunds to support this activity have been provided by Clorox Healthcare.

AUTHORS/PLANNING COMMITTEE/REVIEWER Judith I. Pfister, RN, BSN, MBA Aurora, COProgram Manager/Planning CommitteePfiedler Enterprises

Julia A. Kneedler, RN, MS, EdD Aurora, COProgram Manager/ReviewerPfiedler Enterprises

Dondra Tolerson, BS, MA Woodstock, GA Medical Writer

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Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this continuing education activity. “Relevant financial relationships” are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Activity Authors/ Planning Committee/Reviewer

Judith I. Pfister, MBA, RN Co-owner of company that receives grant funds from commercial entities

Julia A. Kneedler, EdD, RN Co-owner of company that receives grant funds from commercial entities

Dondra Tolerson, BS, MA No conflict of interest

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Email: registrar@pfiedlerenterprises.com

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Website URL: http://www.pfiedlerenterprises.com

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INTRODUCTIONSome of the primary challenges facing hospitals today include poor perception of care by the community and health insurance reimbursement reductions for hospitals with high rates of healthcare-acquired infections (HAIs) among admitted patients. In a 2013 study published in the Journal of Infection Control and Hospital Epidemiology, researchers concluded that treatment systems using ultraviolet (UV) light can effectively reduce environmental contamination and potentially mitigate infection risks.1 Although the use of UV in healthcare facilities is not new, the use of UV-C devices for surface treatment is a recent development, and a growing number of hospitals are implementing these devices as an extra layer of protection to supplement manual cleaning and disinfection with EPA-registered surface disinfectants.

ULTRAVIOLET (UV) LIGHT TECHNOLOGyWhat Is UV Light?Natural ultraviolet light is generated by the sun and is part of the electromagnetic spectrum. UV is characterized by the emission of energy in a portion of the spectrum that falls between x-ray and visible light as seen in Figure 1.2

Figure 1 – Comparison of Wavelength, Frequency and Energy for the Electromagnetic Spectrum3

Credit: NASA’s Imagine the Universe

The terms used to describe UV light are defined as follows4:• Wavelength – The distance between corresponding points of two consecutive

waves, typically expressed in units of meters, micrometers or nanometers.• Watt – Unit of power.• Joule – Unit of energy, or the work required to produce one Watt of power for

one second, typically expressed in units of watt second (W∙s). • Intensity (a.k.a. “Irradiance”) – The amount of UV power delivered to a target

surface area, typically expressed in units of W/m2 • Dose – The amount of UV energy delivered to a target surface area, equivalent

to Intensity ∙ Time, typically expressed in units of J/m2.

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Figure 2 – UV-A, UV-B and UV-C5

UV light has no color equivalent and is referred to by name, most commonly UV-A, UV-B and UV-C. Sunlight that reaches our body is composed of two types of harmful rays. UV-A rays cause aging and UV-B rays cause burns. UV-C is the strongest but in nature it is absorbed by the ozone layer. UV-C devices generate UV-C light and can be used to treat water, surfaces and air by destroying single celled organisms.

As illustrated in Table 1, the categories of UV light are as follows6:• UV-A – Long wave UV is not blocked by glass.• UV-B – Most solar UV-B is absorbed by the ozone layer and blocked by glass. • UV-C – Short wave UV, which includes germicidal ultraviolet used for air,

surface and water treatment.

Table 1 – Classifications of UV Light

Name Abbreviation Wavelength Range (nm) Common Use Potential Risks

Ultraviolet A UV-A 315 nm-400 nm Tanning salons, black lights

Premature skin aging

Ultraviolet B UV-B 280 nm-315 nm Medical treatment, curing

Sunburn and unhealthy effects on skin and eyes with prolonged exposure

Ultraviolet C UV-C 100 nm-280 nm Microorganism inactivation

Skin redness and eye irritation

UV-C for Microorganism InactivationThe use of UV-C light is a recognized and reliable method of microorganism inactivation that involves exposing air, water or contaminated surfaces to UV-C light. UV light penetrates the deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of microorganisms,

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disrupts the cell’s genetic material and impedes reproduction. Although several mechanisms for cell inactivation may occur, the most prevalent is a thymine dimerization reaction that occurs within DNA (illustrated in Figure 3) or a uracil dimerization in RNA.7

Figure 3 – Cell DNA Inactivation Due to UV-C Exposure8

Credit: NASA’s Earth Observatory/David Herring

When microbes are irradiated with the appropriate dosage of UV-C, most cells will no longer be infectious because they cannot replicate.

UV-C TECHNOLOGy IN HEALTHCAREUV technology has been used in germicidal air and water treatment applications since the early 1900s, and has been used in healthcare settings since the 1930s, but has only recently been adopted for surface treatment in hospitals in 2009.9 UV-C devices are ideal for terminal cleaning of patient rooms, emergency rooms, oncology units, intensive care units, outpatient treatment rooms, bathrooms, operating rooms and other high-risk areas. It can be used on walls, bedrails, bedside tables, wheelchairs, mattress covers and other medical surfaces. UV treatment does not replace manual cleaning and disinfection protocols, but UV-C devices can augment manual cleaning and disinfection to provide an extra layer of protection for hospital patients, staff, and visitors.

The Use of UV-C Devices in Patient Care AreasPathogens can survive on surfaces anywhere from several days to several months10 (see Table 2) and according to research published by Bhalla, et al, only about 50% of

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surfaces in hospital operating rooms or patient care rooms are effectively disinfected.11 As would be expected, rooms occupied by infected patients result in higher probabilities of subsequent patient infection.

Table 2 – Surface Viability of Microorganisms12

UV-C is a line of sight technology,13 which means that destruction of microorganisms is achieved when they are in direct line of sight of the UV-C device. As such, all common touch surfaces should be exposed to the UV light.

Using UV-C Devices to Address Healthcare-Associated Infections (HAIs)HAIs are infections that patients develop during the course of receiving healthcare treatment and are the most frequent adverse event in healthcare delivery worldwide.14 HAIs can be caused by a variety of pathogens including C. difficile and Vancomycin-Resistant Enterococci (VRE).15 Microorganisms can infect patients through a wound, via a device such as a catheter, via ingestion, or through the air. The annual number of HAIs in acute care hospitals in the United States in 2011 was estimated to be 722,000 and resulted in 75,000 deaths.16 HAIs have been estimated to cost U.S. hospitals an average of $9.8 billion per year for the five most prevalent HAIs,17 and up to $45 billion in overall annual direct medical costs for all HAIs.18

The continued prevalence of HAIs prompted the Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA), in partnership with the American Hospital Association (AHA), Association for Professionals in Infection Control and Epidemiology (APIC) and the Joint Commission, to update the 2008 recommendations for the prevention of common HAIs.19 The 2014 Compendium Updates include basic HAI prevention strategies in addition to new approaches to reduce colonization, transmission and infection of specific pathogens through advanced environmental decontamination devices.20,21 The threat of HAIs has also encouraged hospitals to seek innovative solutions, such as UV-C devices, to help improve patient safety and reduce the pathogens that cause incidences of HAIs.22

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Limitations of UV-C DevicesAs with any treatment method, the use of UV-C for microorganism inactivation has some limitations. These include the following:

• Efficacy decreases in areas not in direct path of UV-C light.• UV-C devices generally show diminished micro-efficacy when used on surfaces

with gross soil or with organic matter.• Pathogen reduction is related to the UV dose delivered to a particular surface,

and it is influenced by:o The power emitted from the device, which is device-dependent;o The distance between the device and the surface to be treated; o The exposure time of the surface.

• There are currently no established industry standards for hospital surface treatment with UV devices; manufacturers’ protocols vary.

CONCERNS ABOUT THE USE OF UV-CInadvertent UV-C ExposureWhen using UV-C devices, questions may arise regarding safe exposure time and the potential risk of accidental exposure. According to The National Institute for Occupational Safety and Health (NIOSH) at the Centers for Disease Control and Prevention (CDC), the recommended exposure limit for UV-C is 6000 microwatt-seconds per square centimeter (6 mJ/cm2) for a daily eight-hour work shift.23 Additionally, manufacturer’s guidelines should always be followed and UV-C treatment should be performed in unoccupied rooms with a warning sign placed on or outside the door as an added precaution when the devise is in use. Although excessive UV-C exposure has the potential to superficially make skin red and eyes feel painful and gritty, these symptoms typically subside within 24 to 48 hours.24

UV-C Device Safety FeaturesWell-designed UV-C devices have safety controls and procedures to minimize the risk of UV-C exposure. For example, there is a device on the market that is fitted with passive infrared (PIR) safety sensors that are triggered by motion and changes in the infrared radiation above a predefined value (this is different from a motion sensor that detects only motion; this type of sensor could be triggered by insignificant movements). When a door is opened and a person enters the room, the safety sensors detect the person’s body heat and shut the device down within seconds.25

Odor Associated with UV Treatment Healthcare providers might note a peculiar scent following the use of a UV-C device. Boyce et al. noted that there was an odor in treated hospital rooms immediately after completing a UV light decontamination cycle, but the odor dissipated rapidly and, as shown, was not due to ozone generation. Manufacturers should be able to provide air analyses that demonstrate that volatile organic compounds are not generated by their UV-C device at levels above the threshold limit value for exposure set by the Environmental Protection Agency (EPA).26

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The Potential for Mercury ExposureElemental mercury is a naturally occurring chemical element that is a shiny-white liquid at room temperature, and a colorless, odorless gas when heated.27 The function of UV-C lamps depends on pressurized mercury vapor. When a mercury UV-C lamp is turned on, an electric current is discharged. Argon gas carries the discharge (ie, electrons) while the lamp warms up and provides the heat needed to vaporize the mercury and bring it into the discharge. Excited mercury atoms then emit visible and UV light. Typical germicidal mercury lamps used in UV-C devices are low pressure and emit a strong narrow-band in the UV-C spectrum at 253.7 nm.28 When used appropriately, the mercury lamps contained in UV-C devices do not produce a safety hazard. UV-C device lamps contain only about 20 mg of mercury per lamp, which is comparable to four-foot fluorescent bulbs found in overhead lighting.29 This amount of mercury is significantly lower than the amount of mercury found in many other commonly used devices in hospitals; blood pressure monitors, for example, each contain approximately 70 to 90 grams (ie, 70,000 to 90,000 mg) of mercury.30 Figure 4 shows the primary sources of mercury found in seven northern California hospitals.

Figure 4 – Mercury Sources in Seven Northern CA Hospitals31

UV-C LIGHT EFFICACyIt is well documented that UV-C is a highly effective germicide for air and water treatment, and studies on UV-C surface treatment are now emerging in the literature. In fact, an authoritative published book on UV for germicidal applications states that “given sufficient exposure time, any exposed pathogen can be inactivated.”32 However, UV-C efficacy is dependent on several variables some of which include:

• lamp intensity,• exposure time,

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• distance and placement of lamps,• absorbance/reflectance of times in the area, and • direct line of sight.

In essence, the manner in which the device is designed and used can affect efficacy.33

However, evaluating microorganism claims for different UV-C devices is difficult because the US Environmental Protection Agency (EPA) does not currently require registration of pesticide devices, including UV-C devices, and thus there is no standardized method for micro-efficacy testing. Reputable manufacturers use respected third parties to generate micro-efficacy data with full transparency about the test conditions.

Dose Verification CardsSome UV-C devices use UV dose cards to measure the UV-C dose hitting surfaces. After a UV-C device is used, the dose card is placed on the cured surface to verify that the appropriate level of UV-C was delivered. The dose card changes color when exposed to UV-C energy and that color change is calibrated to specific germicidal dose levels. The does cards help eliminate the guesswork of determining when sufficient UV-C dose levels have reached their targeted surface and can be used when establishing protocols for room treatment, quality audits, training and record keeping.

UV-C LITERATUREMicroorganism Reduction StudiesMuch of the peer-reviewed published literature on UV-C for surface treatment covers microorganism reduction in a clinical or laboratory setting. As an example, Dr. William Rutala conducted two separate studies on two different mercury-based UV-C devices to evaluate the performance of each UV-C device against C. difficile and MRSA in a clinical setting.34,35 The studies used similar methods, and both studies were carried out in standard hospital rooms. For each study, Formica sheets were inoculated with C. difficile or MRSA, then placed in different locations in a hospital room, and finally treated with UV-C. One of the UV-C devices was run for 5 and 10 minutes for MRSA and C. difficile, respectively, and the other was run for 15 and 50 minutes for MRSA and C. difficile, respectively. Following cycle completion, log reductions were obtained. The log reductions obtained for each device against MRSA and C. difficile were comparable, but one device achieved the same log reductions in 3- and 5-fold less time (for MRSA and C. difficile respectively). The researchers hypothesized that the differences observed between the UV-C devices could be attributed to device design.

Healthcare-Acquired Infection (HAI) Reduction StudiesVarious additional studies have been conducted that analyze the impact of UV-C devices on HAIs in hospital settings. At Westchester Medical, Janet P. Haas analyzed 52 months of healthcare-acquired MDROs plus C. difficile before and during UV device use. Throughout the pre-UV treatment period (January 2009-June 2011), the hospital used standard cleaning protocols (sodium hypochlorite) to disinfect MDRO patient rooms when

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they were discharged. From July 2011-April 2013 the hospital used two UV machines and added them into their cleaning regimen. After using these UV-C devices to disinfect 22% of their discharges, the facility reported a 20% drop in C. difficile and MDRO infection rates.36 In a similar study conducted in 2011, two UV devices were added to routine hospital discharge cleaning in patient rooms and resulted in a 53% reduction in C. difficile infection rates and reduction in the number of deaths and colectomies attributable to C. difficile.37

SELECTING THE RIGHT UV-C TECHNOLOGy Many manufacturers supply UV-C devices so it can be difficult to assess which one will meet the needs of an individual facility. Healthcare organizations should consider several factors when selecting UV-C technology for their facility:• Manufacturing Experience and Quality

o How much experience does the manufacturer have in the UV technology industry?

o Is the device manufactured in an EPA-registered establishment?o Does the manufacturer hold any certifications showing their

dedication to industry accepted manufacturing practices?• Device Testing

o Has the device been rigorously tested for performance and reliability?o Have the lamps been rigorously tested for performance over their

lifetime?o Have the lamps been rigorously tested to determine the cycled use

lifetime (versus continuous-on time)?o Is the device supported with rigorous and transparent microefficacy

testing?o Has the device been tested in a clinical setting?

• Logisticso Does the company include clear directions for use for UV surface

treatment?o Does the recommended cycle time allow for room turn-over that is

fast enough to meet facility needs?o Does the company provide assistance with development of standard

operating procedures?o Is the device easy to maneuver and transport within the facility?o Is the device easy to program and use?

• Affordability o Does the device provide value to the facility that matches the cost of

the device?o What is the cost of replacing the lamps, and how often do they need

to be replaced?o Are there other costs, such as required warranties and service plans

that will add to the total purchase price?

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• Safetyo Does the device have appropriate safety features, such as motion

sensing capabilities, warning sign(s), and remote start/stop features?o What is the manufacturer’s recommendation for lamp disposal, and

do they provide assistance with lamp disposal if requested?• Customer Care and Support

o Does the company provide in-person training?o Does the company provide ongoing support following device

purchase?o What is their committed response time in the event of a system

issue?o Does the company provide public relations and advertising support?

SUMMARyImproved patient safety and optimal health outcomes for patients is the primary mission in healthcare today. HAIs are a serious threat to patient safety as well as a major issue for healthcare providers. Improving protocols and infection prevention practices can help prevent infections acquired in healthcare settings.

One viable option for improving patient, staff, and visitor safety is the adoption of UV surface treatment technology. UV surface treatment technology is an emerging method to help reduce HAI-causing pathogens. UV-C inactivates vegetative, spore forming, fungal and protozoan microorganisms at the appropriate dose and exposure and can be used as a supplement to standard manual disinfection and cleaning protocols.

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GLOSSARyCenters for Disease Control A Federal agency that conducts and supports and Prevention (CDC) health, prevention and preparedness activities in the United States with the goal of improving overall public health. Established in 1946 and based in Atlanta, the CDC is managed by the Department of Health and Human Services (HHS).

Clostridium difficile Infection An infection of the colon caused by the bacterium (CDI) Clostridium difficile (C. difficile). The infection causes colitis by producing toxins that damage the lining of the colon.

Dimerization A chemical reaction that joins two identical molecular subunits, resulting in the formation of a single dimer.

Decontamination The process of cleansing an object or substance to remove contaminants such as microorganisms or hazardous materials, including chemicals, radioactive substances, and infectious pathogens.

Deoxyribonucleic Acid (DNA) The primary carrier of genetic information found in the chromosomes of almost all organisms.

Environmental Protection An US federal government agency created to Agency (EPA) protect human health and the environment. The EPA is responsible for maintaining and enforcing national standards under a variety of environmental laws.

Healthcare-Associated Infections Infections developed by patients during the (HAIs) course of receiving healthcare treatment for other conditions.

Intensity The amount of UV power delivered to a target surface area, typically expressed in units of W/m2.

Irradiance The amount of UV power delivered to a target surface area, typically expressed in units of W/m2.

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Pathogen A bacterium, virus, or other biological agent that can cause disease or illness to its host.

Ribonucleic Acid (RNA) A nucleic acid present in all living cells. Its principal role is to act as a messenger carrying instructions from DNA for controlling the synthesis of proteins, although in some viruses RNA rather than DNA carries the genetic information.

Thymine Dimerization Formation of a chemical bond between two thymine bases in DNA.

Uracil Dimerization Formation of a chemical bond between two uracil bases in RNA.

Wavelength The distance between corresponding points of two consecutive waves, typically expressed in units of meters, micrometers or nanometers.

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REFERENCES1. Sitzar B. An Environmental Disinfection Odyssey: Evaluation of Sequential

Interventions to Improve Disinfection of Clostridium difficile Isolation Rooms. Infection Control and Hospital Epidemiology. 2013;34(5):459-465.

2. Mills P. [PDF] Ultraviolet (UV) Measurements: For formulators, Part 1. EIT Incorporated. http://www.eit.com/instruments/UVMeasurementForFormulatorsPart1_PaintAndCoatings.pdf Accessed on May 24, 2015.

3. National Aeronautics and Space Administration (NASA). Astronomer’s Toolbox: The Electromagnetic Spectrum. http://imagine.gsfc.nasa.gov/science/toolbox/emspectrum1.html. Accessed July 28, 2015.

4. Encyclopedia Britannica. Light. http://www.britannica.com/science/light. Accessed July 14, 2015.

5. Carlowicz M. The Ozone Layer: Our Global Sunscreen. American Chemical Society (ACS). 2013 April. http://www.acs.org/content/acs/en/education/resources/highschool/chemmatters/past-issues/archive-2012-2013/ozone-layer-our-global-sunscreen.html. Accessed July 14, 2015.

6. World Health Organization (WHO). Ultraviolet radiation and health. http://www.who.int/uv/uv_and_health/en/. Accessed July 14, 2015.

7. Kaufmann WK. The human intra-S checkpoint response to UVC-induced DNA damage. Carcinogenesis. 2010 May;31(5):751-765. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899860/. Published 2009 Sep 30. doi: 10.1093/carcin/bgp230.

8. Herring D. UV Exposure Has Increased Over the Last 30 Years, but Stabilized Since the Mid-1990s http://www.nasa.gov/topics/solarsystem/features/uv-exposure.html. Accessed July 14, 2015.

9. Kowalski W. Ultraviolet germicidal irradiation handbook: UVGI for air and surface disinfection. Cincinnati, OH: Springer; 2009:295.

10. Krammer A, et al. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases. 2006;6:130.

11. Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients. Infection Control Hospital Epidemiology. 2004;25(2):164-167.

12. Krammer A, et al. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases. 2006;6:130.

13. Rutala W, et al. Optimum-UV study: Room decontamination using an ultraviolet-c device with short ultraviolet exposure time. Infect Control Hosp Epidemiol. 2014;35:1070-1072.

14. World Health Organization (WHO). Health care-associated infections: Fact Sheet. http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf Accessed July 15, 2015.

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15. Centers for Disease Control and Prevention (CDC). Healthcare-associated infections: Data and statistics. http://www.cdc.gov/HAI/surveillance/index.html. Accessed June 28, 2015.

16. Centers for Disease Control and Prevention (CDC). Healthcare-associated infections: Data and statistics. http://www.cdc.gov/HAI/surveillance/index.html. Accessed June 28, 2015.

17. Zimlichman E. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Medicine. 2013.

18. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention; Published March 2009. http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Accessed July 28, 2015.

19. The Society for Healthcare Epidemiology of America (SHEA). Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. http://www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspx. Accessed May 27, 2015.

20. The Society for Healthcare Epidemiology of America (SHEA). Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. http://www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspx. Accessed May 27, 2015.

21. Septimus E, Weinstein RA, Perl TM, et al. Approaches for preventing healthcare-associated infections: Go long or go wide? Infection Control. 2014;35:797-801. doi:10.1086/676535.

22. Donskey CJ. Does improving surface cleaning and disinfection reduce healthcare-associated infections? American Journal of Infection Control. 2013 May;41(5):S12-S19. http://www.ajicjournal.org/article/S0196-6553(13)00055-2/fulltext. Accessed July 28, 2015.

23. Kowalski W. Ultraviolet germicidal irradiation handbook: UVGI for air and surface disinfection. Cincinnati, OH: Springer; 2009:295.

24. Sylvain D, Tapp L. UV-C Exposure and Health Effects in Surgical Suite Personnel. Department of Health and Human Services Centers for Disease Control and Prevention (CDC)/National Institute for Occupational Safety and Health (NIOSH). http://www.cdc.gov/niosh/hhe/reports/pdfs/2007-0257-3082.pdf. Accessed on July 19, 2015.

25. Sylvain D, Tapp L. UV-C Exposure and Health Effects in Surgical Suite Personnel. Department of Health and Human Services Centers for Disease Control and Prevention (CDC)/National Institute for Occupational Safety and Health (NIOSH). http://www.cdc.gov/niosh/hhe/reports/pdfs/2007-0257-3082.pdf. Accessed on July 19, 2015.

26. Boyce JM, et al. Terminal decontamination of patient rooms using an automated mobile UV light unit. Infection Control and Hospital Epidemiology. 2011. http://www.researchgate.net/publication/51501845_Terminal_Decontamination_of_Patient_Rooms_Using_an_Automated_Mobile_UV_Light_Unit. Accessed July 28, 2015.

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27. Environmental Protection Agency (EPA). Elemental Mercury: TECH Chemical Summary. http://www.epa.gov/teach/chem_summ/mercury_elem_summary.pdf. Accessed July 28, 2015.

28. Kowalski W. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection. Cincinnati, OH: Springer; 2009:295.

29. Aucott, M, et al. Release of Mercury from Broken Fluorescent Bulbs. Environmental Assessment and Risk Analysis Element. February 2004.

30. Environmental Protection Agency (EPA). [PDF] Eliminating Mercury in Hospitals. Environmental Best Practices for Health Care Facilities. 2002 (Nov). http://www.epa.gov/region9/waste/p2/projects/hospital/mercury.pdf. Accessed May 24, 2015.

31. Environmental Protection Agency (EPA). [PDF] Eliminating Mercury in Hospitals. Environmental Best Practices for Health Care Facilities. 2002 (Nov). http://www.epa.gov/region9/waste/p2/projects/hospital/mercury.pdf. Accessed May 24, 2015.

32. Kowalski W. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection. Cincinnati, OH: Springer; 2009:295.

33. Kowalski W. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection. Cincinnati, OH: Springer; 2009:295.

34. Rutala W, et al. Optimum-UV study: Room decontamination using an ultraviolet-c device with short ultraviolet exposure time. Infect Control Hosp Epidemiol. 2014;35:1070-1072.

35. Rutala W, et al. Tru-D study: room decontamination with UV radiation. Infect Control Hosp Epidemiol. 2010;31:1025-1029.

36. Haas JP, et al. Implementation and impact of ultraviolet environmental disinfection in an acute care setting. American Journal of Infection Control. 2014;42(6):586-590. http://www.ajicjournal.org/article/S0196-6553(13)01432-6/fulltext. Accessed on July 21, 2015.

37. Levin JL, et al. The effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated Clostridium difficile Infection in a community hospital. American Journal of Infection Control. 2013 August;41(8):746-748. http://www.ajicjournal.org/article/S0196-6553(13)00249-6/fulltext. Accessed on July 21, 2015.

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