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The Horizontal approach to Preventing

HAIs; What role does the Environment

Play?

Linda R Greene, RN,MPS,CIC

Manager Infection Prevention

UR Highland Hospital

Rochester, NY

linda_greene@urmc.rochester.edu.

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Objectives

• Describe the role of hospital environment in infection

prevention

• Identify evidence based practices to ensure appropriate

environmental hygiene

• Describe pitfalls in implementation of evidence based practices

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How Does a Patient Get an Infection?

Chain of Infection

Agent

Reservoir

Portal of exit

Mode of transmission

Portal of entry

Susceptible host

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Septimus et. al ICHE

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Potential Importance of Environmental Surfaces in

Transmission of Nosocomial Pathogens

• Organisms may survive for long periods of time on nonporous

surfaces

• Active surveillance not done on most patients for nosocomial

pathogens

• Healthcare workers (HCWs) frequently do not wash hands

after contact with patients and/or surfaces without direct

patient contact

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The Case for Environmental Hygiene

• Previously contaminated rooms increase transmission risk

• Many patient rooms not well cleaned

• Cleaning process can be improved in most organizations

• Improved cleaning decreases environmental contamination

• Improved cleaning decreases acquisition of pathogens

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Schaefer MK, et al. JAMA. 2010;303(22):2273-2279.

19% of facilities did not appropriately clean

high-touch surfaces in patient care areas

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“I just touched the bed rail…”

100-1,000 bacteria transferred by:

• Pulling patients up in bed

• Taking a blood pressure or pulse

• Touching a patient’s hand

• Rolling patients over in bed

• Touching patient’s gown or bed sheets

• Touching equipment like bedside rails, over-bed tables, IV pumps

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53% of HCWs Hand Imprint Cultures + After Occupied

Room vs 24% of Clean Empty Rooms

Bhalla A, et al. Infect Control Hosp Epidemiol.

2004;25(2):164-167.

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Basic, but important principle

Epidemiologic triangle of cross transmission

Most MDRO*s are transmitted via hands of HCWs

Kramer A BMC Infect Dis 2006;6:130

*MDRO= Multi-Drug Resistant Organisms

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Microbiologic factors that can facilitate surface

environment-mediated transmission of selected pathogens

• Pathogen able to survive for prolonged periods of time on environmental surfaces (all pathogens)

• Ability to remain virulent after environmental exposure (all)

• Contamination of the hospital environment frequent (all)

• Ability to colonize patients (Acinetobacter, C difficile, MRSA, VRE)

• Ability to transiently colonize the hands of health care workers (all)

• Transmission via the contaminated hands of healthcare workers (all)

• Small inoculating dose (C difficile, norovirus)

• Relative resistance to disinfectants used on environmental surfaces

• (C difficile, norovirus)

Weber DJ, et al. AJIC 2010

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Renewed Respect for Role of the Environment:

Who’s Been in the Room Before or With You?

• Huang SS (2006);

• Drees M (2008);

• Zhou Q (2008);

• Moore C (2008);

• Hamel M (2010)

– All documented increased risk of

acquisition of VRE, MRSA, &/or CDI

when admitted to room where prior

occupant had one of these or if in multi-

occupancy room

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Additional Evidence: Single Occupancy Rooms

• Rate of Acquisition of C. difficile, VRE, & MRSA decreased by

54% after conversion from multi- to single occupancy ICU

rooms

• Ave. length of stay dropped by 10%

• No change in acquisition of coag.-negative Staphylococci

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Pendulum

Role of the Environment

70’s and 80’s

90”S

2000 forward

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Changing Goals

Past Present

Healthcare

Environment

Goal

Shinier Floors Safer

Environment

Surface

Bioburden

Reduction

Disinfectant

Efficacy

Hygienic

Practices

Technologic

Advancements

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It’s Not Just About Shiny Floors

She needs to

get a life!

No, not shiny enough

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Role of hospital surfaces in transmission

of emerging health-care pathogensCharacteristic Norovirus C difficile Acientobacter

Prolonged enviornmental survival x x x

Contamination in rooms of infected patients

x x x

Contaminated resorvoir during an outbreak

x

Level of contamination associated with frequency of HCW hand contamination

x

Risk following admission to room

Following infected patientx

Reduction by enhanced cleaning x x

Weber et al AJIC 2010 Vol 38 N 5 Supplement

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Survival of Pathogens on Surfaces

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Transfer of Pathogens

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Principles of Cleaning and Disinfection

Important to Remember:

• Cleaning refers to the removal of visible soil and organic

material

• Thorough cleaning is needed before disinfection or

sterilization because organic material can decrease the

effectiveness of those processes.

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Need for Improved Healthcare Environmental

Cleaning: Literature Support

Carling P, Bartley J. Am J Infect Control. 2010;38:S41-S50.

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Environmental Contamination

“Fecal Veneer”

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C. Difficile Infection

EXPOSURE TO

THE C. DIFF

ORGANISM

EXPOSURE TO ANTIBIOTICS

SICK PATIENT WITH DIARRHEA

HAPPY PATIENT GOING HOME

Directly

• From Environment

Indirectly

• Through hands of

healthcare

personnel

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ENGAGE:CEO & Senior Leadership

buy-in

Team creation

City-wide prevention and team-building workshops

C difficile collaborative

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Barriers

Assumption that EVS cleans everything “that’s their job”

Identification of items that need cleaning

Need for a multidisciplinary approach

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Strategies

Source : Barnes Jewish

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Alternate Approach

Item Picture By Whom Frequency

Hand Gel

Dispensers

EVS Daily and as

needed

BP Cuff After use –nursing

Terminal Clean -

EVS

After use and

terminal clean

IV Pumps Nursing Between

Individual patients

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Challenges in Improving Environmental

Cleaning

• EVS has not traditionally been an integral part of the IP team

• Many healthcare institutions run at or near 100% capacity.

Room turnover, quick discharge and admission of new patients

is a priority

• We have not shared outcome data with EVS staff and helped

them to understand the important role they play in infection

prevention

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Proposals to Bring Evidence to the Bedside

• Must involve EVS as an integral part of Infection Prevention

• Share outcome as well as process data

• Enhance observations with objective data

• Require leadership involvement and support

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Consider Enhanced Monitoring Techniques

Method Ease of use

Identifies

pathogens

Useful for

individual

teaching

Directly

evaluates

cleaning

Published

use in

programatic

improvement

Covert

practice

observation

Low No Yes Yes 1 hospital

Swab cultures High Yes Not studied Potentially 1 hospital

Agar slide

cultures

Good Limited Not studies Potentially 1 hospital

Fluorescent

gel

High No Yes Yes 49 hospitals

ATP system High No Yes Potentially 2 hospitals

Carling P, Bartley J. Am J Infect Control. 2010;38:S41-S50.

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Visual Assessment

• Visual assessment can only identify gross lapses in

practice

• Need objective measures and feedback

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The Inanimate Environment Can Facilitate

Transmission

Hayden M, et al. Poster presented at the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy

December 16-19, Chicago, IL. Available at:

http://www.cdc.gov/handhygiene/download/hand_hygiene_supplement_minus_notes.pdf

represents VRE culture positive sites

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Strategies: Education

• Provide an overview of the importance of HAIs in a manner

commensurate with their educational level using as many

pictorial illustrations as is feasible

O² sat monitor Call bell

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Tools

ATP Fluorescent Marker

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Evidence

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Intervention

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Infection Prevention Bundles

Materials provided by Brian Koll, Beth Israel Hospital, New York, NY.

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Challenge: Routine Terminal Cleaning

• Mean proportion of surfaces disinfected at terminal cleaning is

less than 50%

• Routine terminal cleaning methods not effective in eliminating

epidemiologically important pathogens

Carling PC, et al. Infect Control Hosp Epidemiol. 2008;29(11):1035-1041.

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Review Terminal Room Cleaning Practice

Expectations

http://www.cdc.gov/HAI/

recoveryact/

stateResources/

toolkits.html

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Feedback

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Other Considerations

• Increased risk of prior room occupant transmission is 73%1

• Potential for transmission despite enhanced cleaning

procedures

• Novel terminal cleaning and disinfection methods hold

promise2

• Effectiveness depends on a team approach

1. Carling PC, Bartley D. Am J Infect Control. 2010;38(5 Suppl 1):S41-S50.

2. Falagas ME, et al. J Hosp Infect. 2011. doi:10.1016/j.jhin.2010.12.006.

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No Touch Technologies

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Organism Group Member of Group

Vegetative bacteria S. aureus

Strep

E. coli

P. aeruginosa

Serratia

Mycobacteria M. tuberculosis

M. bovis

M. leprae

Bacterial spore B. anthracis

B. cereus

C.diff

Fungal pathogens Aspergillus

Candida

Penicillium

Most Susceptible

Vegetative bacteria

Mycobacteria

Bacterial spores

Fungi

Least SusceptibleGeneral ranking of susceptibility to UVC inactivation of microorganisms by group.

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Overview of Area Decontamination Technologies

Technology Advantages Disadvantages and Safety issues

Gaseous hydrogen

peroxide1

• Active against many pathogens, including

spores

• More effective than manual

cleaning/disinfection

• No toxic by-products

• Published evidence of use in clinical settings

to reduce environmental contamination and

infection rates

• Room must be empty and sealed

• Cannot be used in occupied room

UV disinfection2 • Active against many pathogens

• Relatively simple and easy to use

• No toxic residues

• Eye irritation

• Burning

Cannot be used in occupied room

Ozone3 • Active against many pathogens

• More effective than manual

cleaning/disinfection

• Room must be empty and sealed

• Affected by humidity

• No data on use in clinical setting

1. Shapey S, et al. J Hosp Infect. 2008;70:136-141.

2. Stibich M, et al. Infect Control Hosp Epidemiol. 2011;32(3):286-288.

3. Moat J, et al. Can J Microbiol. 2009;55(8):928-933.

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Overview of Area Decontamination Technologies

(cont)

Technology Advantages Disadvantages and Risks

Gaseous chlorine

dioxide1

• Active against many pathogens,

including spores

• More effective than manual

cleaning/disinfection

• Room must be empty and sealed

• Potentially toxic by-products

• Affected by UV light and humidity

• Can discolor some materials

• No data on use in clinical setting

• Explosive at >10%

Gaseous hydroxyl

radicals2

• Can be used while room is occupied

• Silent and odorless

• Limited data on effectiveness against

nosocomial infections

Air filtration

technologies3

• Can be used whilst room is occupied

• Proven effectiveness at reducing

environmental contamination rates

• Noisy

• Requires regular cleaning and filter

changes

1. Hubbard H, et al. Environ Sci Technol. 2009;43(5):1329-1335.

2. Wong V, et al. J Hosp Infect. 2011;78:194-199.

3. Qian H, Li Y. Indoor Air. 2010;20(4):284-297.

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Inputs to Consider When Developing Disinfection

Strategies

How critical is time for a given use area?

Acute ----------------------------------------- Routine

Clusters Isolation

Rooms

Specialty

(OR, Cath)Patient

Rooms

Important Not Important(Effectiveness)

Risk

Needs

Time

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Successful Implementation & Creating Enhanced

Bundles

• Work collaboratively with EVS

• Develop a plan

• Identify high priority areas based

upon risk assessment

• Establish how and when

enhanced room disinfection

strategies will be used

• Successful integration of new

technologies

• Monitor implementation

Clean Sweep

• Useful during outbreaks or times of high endemicity

• Patients are moved to an empty room and room disinfected. Patient then moved to that room, etc

Focused

• Terminally clean all rooms in high risk area based upon preset timeline

• Limit to specific types of rooms (isolation)

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Identifying Areas for Enhanced Cleaning

• Requires shutdown of room/unit

• Longest accepted time frameClusters

• Requires enhanced procedures (gown/glove)

• Less time constraintIsolation rooms

• High level of concern

• Linked to environment

• Cause of clustersSpecific pathogens

• Down-time off-hours

• Night-time terminal cleaningOR/Cath/Endoscopy

• Routine deep-clean in unit

• Periodic deep clean in patient rooms“Spring Cleaning”

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Summary

• There is a clear need for better cleaning and disinfection of the

hospital environment

• Improved hospital environmental decontamination is possible

through

– Integration and education of EVS personnel

– Team approach

• Potential for transmission despite enhanced cleaning

procedures, therefore an ongoing need for novel terminal

cleaning and disinfection methods

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Enviornmental Hygiene is now at Team Sport

http://youtu.be/1qzzYrCTKuk