Improving Environmental Cleaning and Disinfection in Healthcare Settings

Massachusetts Coalitionfor the

Prevention of Medical Errors

March 26, 2008

A New Metric for an old Job

How Important is Environmental Contamination in Hospitals?

Philip C. Carling, M.D.Director of Infectious Diseases and Hospital

Epidemiology at Carney Hospital and Faculty of Boston University School of Medicine

Contaminated Surfaces

Bed Rails +++++++ + +++Bed Table ++++++ + Door Knobs ++ ++ +Doors +++ + Call Button +++ + ++Chair ++ + ++Tray Table +++ ++ Toilet Surface + ++++Sink Surface + + +++Bedpan Cleaner +

VRE MRSA C. difficile

P. Carling, M.D. 3/08

Surface Contamination of Near-patient Environment

23 Studies

0

20

40

60

80

100

C. DIFFICILE VRE MRSA

% C

ON

TAM

INA

TED

P. Carling, M.D. 3/08

Survival of Pathogens on Environmental Surfaces

C. Difficiele – > 5 months MRSA – 90 to > 236 d. VRE – 7 to 120 d. E. coli O157 – > 60 d.

Rhinoviruses – Several hours Hepatitis A – > 4 hours Parainfluenza viruses – 10 hours

P. Carling, M.D. 3/08

How Well Do Environmental Disinfectants 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

Since surfaces in the “patient zone” are contaminated with environmentally resilient transmissible pathogens such as C. difficile, etc.,

What guidelines are there to direct our disinfection cleaning practice to mitigating the problem?

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

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

CMS

How Well Does Environmental Cleaning Work ?

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

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

P. Carling, M.D. 3/08

Targeting Patient Rooms

Targets were chosen by considering sites A. A patient was most likely to contaminate and B. A care givers may touch with their hands

Between 8 -10 Targets marked in each room after terminal cleaning

Targets were evaluated after one to two patients had cycled through the room

P. Carling, M.D. 3/08

Preliminary Results – Three Hospitals

45 42

56

8682

92

0

20

40

60

80

100

% O

BJEC

TSCL

EANE

D

HOSPITAL A HOSPITAL CHOSPITAL B

Clinical Infectious Diseases – February 2006P. Carling, M.D. 3/08

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

The Healthcare Environmental Hygiene Study Group

0

2

4

6

8

1-5% 11-15%

21-25%

31-35%

41-45%

51-55%

61-65%

71-75%

81-85%

91-95%

Baseline Environmental Evaluation of 35 Acute Care Hospitals

% of Objects Cleaned

Hos

pita

ls

Mean = 48.5 %

P. Carling, M.D. 3/08

PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS

0

20

40

60

80

100

%

P. Carling, M.D. 3/08

The Program

Phase I – Covert Baseline Environmental Evaluation

Phase II

A. Educational Interventions – ES Staff

B. Feedback to the ES – Staff

P. Carling, M.D. 3/08

40

50

60

70

80

Hospitals Environmental Hygiene Study Group Hospital Results

% o

f O

bjec

ts C

lean

ed

PRE INTERVENTION POST INTERVENTION

P. Carling, M.D. 3/08

Healthcare Environmental Hygiene Study Group

Current 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

P. Carling, M.D. 3/08

Does it make a difference?

0

1

2

3

4

5

6

7

8

9

1994 1996 1998 2000 2002 2004 2006 2008

PU

BL

ISH

ED

RE

PO

RT

S

ENHANCED CLEANING = DECREASED INFECTION

ENVIRONMENTAL PATHOGENS TO HCW HANDS

ENVIRONMENTAL PATHOGENS TO PATIENTS

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

P. Carling, M.D. 3/08

Thanks for your interest!

Carling PC, Briggs JL, Perkins, J and Highlander D. Improved cleaning of patient rooms using a new target method. Clinical Infectious Diseases 2006;42:385-8.

Carling PC, Parry ML, SM Von Beheren; for the Healthcare Environmental Hygiene Study Group. Identifying Opportunities to Enhance Environmental Cleaning in 23 Acute Care Hospitals. Infect Control Hosp Epidemiol 2008;29:1-7.

Questions / Comments: pcarling@cchcs.org

P. Carling, M.D. 3/08