IntroductionIt is well recognised that enhanced environmental cleaning and decontamination are vital components in reducing rates of infection.1 A recent report states that ‘there is now compelling evidence that contaminated surfaces make an important contribution to the epidemic and endemic transmission of C. difficile, VRE, MRSA, A. baumannii and P. aeruginosa and the epidemic transmission of norovirus’.2 A clean environment plays a key role in reducing the risk of infection and underpins all other aspects of infection prevention which take place within the clinical setting.

In recent years the Infection Prevention and Control (IP&C) team at Alder Hey hospital progressed from a two stage cleaning and disinfection protocol (neutral detergent and sodium hypochlorite) to a single stage (chlorine dioxide) cleaning and disinfection process. Although beneficial in terms of process efficiency and fewer staff reporting respiratory problems to occupational health, the use of chlorine dioxide presented the IP&C team with the following issues;

1. Ease of use (product required mixing of sachets, dilution and stirring)2. Product deterioration (loss of efficacy) over time, when diluted and stored ‘ready

for use’3. Staff compliance with cleaning protocols – due to product complexity4. Manual handling issues – lifting 10 litres of fluid from floor level5. Some staff still reported respiratory issues to occupational health6. Use on incubators resulted in discolouration / clouding of the cases7. Cost of the chlorine dioxide product8. Limited cleaning effect on some surfaces / equipment

Aims and ObjectivesThe IP&C team wanted to identify and adopt a chlorine free disinfectant technology for all hospital disinfection and cleaning. In addition, any new product had to be: non-toxic; easy to use; demonstrate broad spectrum efficacy (virucidal, sporicidal, bactericidal, fungicidal etc); a cleaner disinfector (single step); cost effective over the current (chlorine dioxide) cleaning product and available in a wipe based format.

MethodPrior to changing from chlorine dioxide to an alternative cleaning / disinfection technology the IP&C team performed the following two stage evaluation process;

Stage 1: A ‘table-top’ review to determine product efficacy; safety; cost; and availability of appropriate product formats (solution; wipes; hand sanitiser).

Stage 2: An ‘in-use’ clinical product evaluation to determine product effectiveness (using Adenosine Triphosphate (ATP) swab testing of multiple high-touch surfaces); ease of use and user acceptance.

After passing ‘stage 1‘ with a review of the appropriate technical documentation for TECcare® CONTROL (Material Safety Data Sheets; In-vitro efficacy test data (EN test reports); product pricing; available product formats) the IP&C team set up ‘stage 2’ of the assessment, an ‘in-use’ clinical product evaluation to determine product performance, ease of use and user acceptance. The evaluation took place within a twenty one bed cardiology ward (with a six bed high dependency bay) and a fifteen bed high dependency unit. Standard (chlorine dioxide) products were used for cleaning all clinical environmental surfaces and equipment during week one (providing ‘baseline’ ATP readings for comparison), then TECcare® CONTROL solution and wipes (see Figure 1) were used for cleaning all clinical environmental surfaces and equipment for week two. In addition to the change in cleaning product TECcare® PROTECT hand sanitiser was also used by the clinical staff working on the two ward areas. All other aspects of cleaning and disinfection remained unchanged.

Throughout the two week evaluation ATP swab testing took place every two days at eighteen predetermined ‘high touch’ locations across the two clinical areas. Swab test locations are detailed in Table 1.

Selecting a suitable alternative to chlorine baseddisinfection for environmental cleaning

JO KEWARD, CNS Infection Prevention & Control, Alder Hey Children’s NHS Foundation Trust

Poster produced by TECcare® in association with Alder Hey Children’s NHS Foundation Trust. TECcare® have provided the author of this poster with conference sponsorship only. No other funding has been provided.

References1. Department of Health. Clean, safe care: Reducing infections and saving lives. 2008. [cited 2013 Mar 28].

Available from: www.dh.gov.uk/publications2. Pyrek KM. Special Report. HAI Prevention and Environmental Hygiene: The Changing Landscape of

Healthcare Delivery. Infection Control Today [serial online]. 2013 Feb [cited 2013 Mar 28]; [28 screens]. Available from: http://www.infectioncontroltoday.com/reports/2013/02/hai-prevention.aspx

3. Sherlock O, O’Connell N, Creamer E, Humphreys H. Is it really clean? An evaluation of the efficacy of four methods for determining hospital cleanliness. J Hosp Infect. 2009 Jun;72(2):140-6.

4. Moore G, Smyth D, Singleton J, Wilson P. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting. Am J Infect Control. 2010 Oct;38(8):617-22.

5. Lewis T, Griffith C, Gallo M, Weinbren M. A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces. J Hosp Infect. 2008 Jun;69(2):156-63

6. Mayfield JL, Leet T, Miller J, Mundy LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis. 2000 Oct;31(4):995-1000.

7. McMullen KM, Zack J, Coopersmith CM, Kollef M, Dubberke E, Warren DK. Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol. 2007 Feb;28(2):205-7.

ResultsSeventeen of the eighteen high touch surfaces subjected to ATP swab testing were physically cleaner when TECcare® CONTROL was used in place of chlorine dioxide (Table 1). Furthermore fifteen of these seventeen locations reported an improvement in cleanliness of sixty to ninety five percent. Similarly the results favour TECcare® CONTROL when assessing environmental cleanliness in terms of ‘pass/fail’ threshold values of 500 and 250 Relative Light Units (RLUs) respectively (Table 1). Combining the RLU scores for all eighteen high touch swab test locations resulted in an overall mean reduction of seventy five percent in favour of TECcare® CONTROL (Table 1). Performing all environmental and equipment cleaning across the two clinical areas with the combined product offering of TECcare® CONTROL solution (with SMART Pump technology) and TECcare® CONTROL wipes resulted in a cleaner clinical environment compared to that achieved when using the previous chlorine dioxide based product.In addition all staff found the TECcare® CONTROL products very easy to use and both the concentrate with SMART Pump technology and the wipes received excellent levels of user acceptance.

Discussion / ConclusionWhilst ATP monitoring cannot determine environmental bioburden it does provide a recognised method with which to quantitatively determine the cleanliness of the clinical environment.3-5 Throughout the in-use evaluation performed at Alder Hey, TECcare® CONTROL outperformed chlorine dioxide in terms of creating a cleaner clinical environment. The importance of creating and maintaining the cleanest possible clinical environment cannot be overstated and with enhanced environmental cleanliness associated with a reduced risk of infections1,2,6,7 the introduction of TECcare® CONTROL offers benefits over the previous chlorine dioxide product.After successful ‘table top’ and ‘clinical’ evaluations in July 2012 the IP&C team were satisfied that TECcare® CONTROL solution and wipes met all of their needs in terms of product safety, efficacy, ease of use, cost, product format, effectiveness and user acceptance. January and February 2013 saw Trust wide adoption of TECcare®

CONTROL products which are now used for cleaning and disinfection of all clinical environmental surfaces and equipment within the hospital.

SWAB TEST LOCATIONMEAN RLU (RANGE) % DIFFERENCE

(FAVOURS TECcare®)(FAVOURS CHLORINE)

ChlorineDioxide

TECcare®

CONTROLTelephone 371 (152-574) 78 (20-152) 79IV prep area 6 (2-10) 16 (0-38) -153Patient table 245 (45-620) 46 (3-77) 81Patient locker 76 (33-107) 38 (2-92) 50Staff entrance touch plate 455(329-704) 99 (6-192) 78Door handle cubicle 18 382(198-611) 83 (5-159) 78Cot / bed frame 256 (111-340) 66 (28-107) 74High chair 853 (580-1227) 259 (15-590) 70Patient bath 204 (30-322) 79 (1-244) 61Medicine trolley 189 (83-302) 71 (31-159) 62Mobile ultrasound probe 338 (150-533) 18 (5-34) 95Notes trolley 174 (125-224) 49 (0-201) 72Bedside TV 236 (158-322) 93 (27-201) 60Top of waste bin 119 (63-154) 44 (13-95) 63Thermometer 587(216-1091) 52 (3-174) 91Control panel ultrasound 391 (138-635) 65 (19-124) 83Baby change rack bottom 130 (23-228) 110 (11-227) 15Baby change rack top 121(50-175) 41 (5-86) 66MEAN SCORE 285 (6-853) 73 (16-259) 75No. swab sites with mean RLU >500 2 0 -No. swab sites with mean RLU >250 9 1 -

Table 1. ATP swab test results (in Relative Light Units (RLU)) for ‘chlorine dioxide’ vs. ‘TECcare®’

Figure 1. TECcare® CONTROL solution with SMART Pump technology and TECcare® CONTROL wipes

TECcare is a registered trademark of Talley Environmental Care Limited (www.teccare.com)