Is Your Facility Clean?DAZO Knows

Sandra Von Behren

03/26/2010 1TSICP

Objectives

• Discuss the role of the environment in the transmission of healthcare-associated infections (HAIs) and multi-drug resistant organisms (MDROs)

• Identify available methods to evaluate environmental cleanliness

• Discuss strategies to improve environmental cleaning and decrease the risk of MDRO and HAI transmission

03/26/2010 TSICP 2

Philip C. Carling, MD

• Boston University School of Medicine

• Department of Epidemiology,Carney Hospital

• Boston, MA

03/26/2010 TSICP 3

The Environment as a Source of Pathogens

• S. aureus– Dancer et al; JHI 2006; 62: 200-206

• MRSA– Boyce et al, ICHE 1997; 18:622-627

• VRE– Bhalla et al, ICHE 2004; 25: 164-167– Hayden, et al, ICHE 2008; 29: 149-154

03/26/2010 TSICP 4

Environmental Contamination: Is There A Link to HAI

Acqusition?

Patients admitted to rooms previously occupied by patients with MRSA, VRE, Acinetobacter baumanii are at risk of acquiring organisms from the environment

03/26/2010 TSICP 5

Huang, et al; Arch Intern Med 2006; 166: 1945-1951Hardy , et al; ICHE 2006; 27: 127-132Sexton et al; JHI 2006; 62: 187-194Martinez, et al; Arch Intern Med 2003; 163: 1905-1912

Environmental Contamination with Antimicrobial Resistant Organisms (MDROs)

0

20

40

Bed Rail Supply Cabinet Bedside Table

Pro

po

tio

n o

f T

es

ted

Ob

jec

ts

%

MRSAVREC, difficiele

Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

Environmental Contamination with Antimicrobial Resistant Organisms (MDROs)

0

20

40

Proportion of Isolates FromObjects Touched Only by

Staff

Pro

po

tion

of A

ll Is

ola

tes

%

MRSA VREAdopted from – Speck SHEA Abstract 167, Baltimore, April 2007

39 % of positive cultures from staff only touched objects were different from those for which the patient was being isolated

Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with

hydrogen peroxide vapour

0

2

4

6

8

10

12

WeekBefore

BeforeCleaning

AfterCleaning

AfterHPV

24Hr.post

4 WeeksPost

6 WeeksPost

MRSA Contamination

Patients Colonized

Adapted from - Hardy KJ et.al J Hosp. Infections 66,360 August 2007

C. Difficile Environmental Contamination

0

3000

6000

PT HANDS NEARENVIRONMENT

DISTANTENVIRONMENT

HCW HANDS

PCR

CO

LON

Y C

OU

NTS

/10c

m2

CDAD + PATIENT WARDS

CDAD - PATIENT WARDS

Mutters R, etal. J Hosp Infect. 2009; 71: 43-48

Survival of Pathogens on Environmental Surfaces

C. difficile > 5 months

Staphylococci 7 months VRE 4 months Acinetobacter 5 months

Norovirus 3 weeks Adenovirus 3 months Rotavirus 3 months SARS, HIV etc. days to week

C. difficile Transmission From Prior Room Occupants

0

10

20

FORMER CDADOCCUPANCY

NO PRIOR CDADOCCUPANCY

% R

ISK

OF

DEVE

LOPI

NG C

DAD

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

C. difficile Transmission to Prior Room Occupants

0

10

20

FORMER CDADOCCUPANCY

NO PRIOR CDADOCCUPANCY

% R

ISK

OF

DEVE

LOPI

NG C

DAD

Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

110% Increased risk

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

HCW

HANDS

SUSCEPTABLE

PATIENTS

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

HCW

HANDS

SUSCEPTABLE

PATIENTS

ISOLATION

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

HCW

HANDS

SUSCEPTABLE

PATIENTS

ISOLATIONHAND

HYGENE

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

ENVIRONMENTAL SURFACES

HCW

HANDS

SUSCEPTABLE

PATIENTS

ISOLATIONHAND

HYGENE

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

ENVIRONMENTAL SURFACES

HCW

HANDS

SUSCEPTABLE

PATIENTS

ISOLATIONHAND

HYGENE

ANTIBIOTIC RESISTANT

PATHOGENS

ON / IN

PATIENTS

ENVIRONMENTAL SURFACES

HCW

HANDS

SUSCEPTABLE

PATIENTS

ISOLATIONHAND

HYGENE

DISINFECTION CLEANING

Prevent Transmission:Hand Hygiene

• Many facilities have had significant improvements

• Microbial resurgence is rapid following HH• Logistical limitations in a complex

environment

03/26/2010 TSICP 20

HH in Complex Intense Environments is Very Difficult

30 to 40 HH “Moments” per Hour during direct patient care

Isolation

• Difficult to implement and maintain• When to Begin—When to stop• Unintended consequences

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Isolation is Difficult

Our review of the literature demonstrates that contact precautions have unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of contact precautions are urgently needed.

Am J Infect Control. 2009 (May); 37: 85-91

What can we do??

Improve effectiveness of environmental cleaning/disinfection patient environment

How Can We Evaluate Environmental Cleaning

• Direct observation• Culture the environment• ATP bioluminescence Tool• Fluorescent marking tool

03/26/2010 TSICP 26

ATP bioluminescence

Swab surface luciferase 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.

ATP Bioluminescence Testing in Healthcare Settings

Potential usefulness:Has been used as a surrogate for environmental culturing

Provides an estimate of cleanliness

Can rapidly define how clean an object is…. but non-microbial ATP is also evaluated

Standards to optimize predictive values are still being evaluated

Can be used to do one-on-one education of ES staff

ATP Bioluminescence Testing in Healthcare Settings

Potential limitations:Secondary cleaning of the site is required to remove

disinfectant induced signal decay or enhancement.

Involvement of the ES staff is implicit since evaluation must be done within minutes of cleaning.

Pre-intervention evaluation of disinfection cleaning is difficult without inducing a Hawthorne effect

Results are individual ES staff / time specific.

Many manufacturers of luminometers and ATP swabs makes interinstitutional standardization difficult

Evaluating Patient Zone Environmental Hygiene

Evaluating Patient Zone Environmental Hygiene

Evaluating Patient Zone Environmental Hygiene

Evaluating Patient Zone Environmental Hygiene

GOAL OF THE PROJECT

To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

Dazo Solution(Initially called “GOO”)

Target After Marking

Target Enhanced

The Targeting Solution

• A mixture of several glues, soaps and a targeting dye which: – Dries rapidly – Remains stable – Easily removed with light abrasion and damp cloth

– Inconspicuous

Cleaned, empty room

identified

Room marked Room evaluated

Terminal cleaning after 1 or 2 patient cycles

Phase I: Covert Baseline Environmental Cleaning Evaluation

Phase II: A. Programmatic AnalysisB. Educational Interventions – ES staff

Cleaned, empty room

identified

Room marked Room evaluated

Terminal cleaning after 1 or 2 patient cycles

Phase III: Re-evaluation of Cleaning and feedback to ES

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 2006

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

Healthcare Environmental Hygiene Study Group – Acute Hospitals (90)

MA = 12RI = 5

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

36 Acute Care Hospitals

% of Objects Cleaned

Hos

pita

ls

Mean = 48.5 %

(20,056 Objects)

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

0

20

40

60

80

100

%

40

50

60

70

80

90

PRE-INTERVENTION POST ED POST SINGLE F/U POST 2-4 F/U

% o

f O

bje

cts

Cle

an

ed

RAPID IMPROVEMENT

DELAYED IMPROVEMENT

LIMITED IMPROVEMENT

17 HOSPITALS

10 HOSPITALS

8 HOSPITALS

Terminal Room Cleaning Project – Three Programmatic Responses

40

50

60

70

80

Hospitals Environmental Hygiene Study Group36 Hospital Results

% o

f Obj

ects

Cle

aned

PRE INTERVENTION POST INTERVENTION

P = <.0001Resource Neutral

TERMINAL ROOM CLEANING INFECTION PREVENTION

TARGETS

Sink and FaucetsToilet SurfacesToilet Flush HandleBedpan CleanerToilet Area HandholdsToilet Area Door Knobs or Push PlatesBedside TableTray TablePatient ChairSide RailsRoom Door KnobsCall BoxTelephoneBathroom Light Switches

Specific Opportunities for Improvement

Focus Group

• Held 4 meetings with Environmental Services (EVS) staff on different shifts– 5-6 staff members in each session– Met for 4 hours– No EVS supervisors present– Meal provided

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Focus Group Questions

• What recommendations do you have to improve cleaning outcomes?

• What barriers do you see that would prevent implementation of these recommendations?

03/26/2010 TSICP 50

Problems Identified

• Staffing not always adjusted to busiest times• Pressure from nursing staff to “get it done”• Supervisors not visible• Staff on evening shift “on call” from one end

of hospital to the other

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Recommendations

• More “on the spot” feedback from supervisors• Help from supervisors to prioritize work• Better communication with nursing• Consistency unit to unit• Maintain level of cleaning done when TJC is

expected• Have a quality control officer• Use Dazo as follow-up to classroom orientation• Evaluation of work efficiencies (Organizational

Improvement)

03/26/2010 TSICP 52

ICU Project

• Daily Clean of Isolation Rooms• Marked room and read in or 2 days

03/26/2010 TSICP 53

Possible Interventions?

• How can we improve on daily disinfection cleanings?• Who is responsible for each item?

-Siderail bed control -Table/counter/workspace-Call button -Computer keyboard-Tray table -Storage drawer handle-Monitor control -Room light switch-Vent control - Room door handles-Commode -IV pump-Sink

Item Responsibility

• Environmental Services:– Tray table– Light switch– Room door handles– Sink– Work surface– Cabinet handles– Call button– In-room commode

• ICU Nursing:– Keyboards– Side rails– IV pumps– Monitor control panel

• Respiratory Therapists:– Ventilator Control Panel

Re-evaluation will take place in 3-4 weeksRe-evaluation will take place in 3-4 weeks

Brigham & Woman’s ICU Study

44

71

45

27

0

20

40

60

80

PRE-INTERVENTION

POSTINTERVENTION

%

THOROUGHNESS OF CLEANING

MRSA/VRE CONTAMINATION

Brigham & Woman’s ICU Study

Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009

Datta R, Platt R, Kleinman K, Huang SS

Brigham & Woman’s ICU Study

Impact of an Environmental Cleaning Intervention on the Risk of Acquiring MRSA and VRE from Prior Room Occupants (SHEA Abstract 273) 2009

Datta R, Platt R, Kleinman K, Huang SS

“For both MRSA and VRE, absolute risk appeared diminished during the intervention regardless of prior occupant status”

Conclusions

• It is likely that surfaces in the Patient Zone are of relevance in the transmission of Healthcare Associated Pathogens.

• While optimizing hand hygiene and isolation practice is clearly important there is no reason why the effectiveness and thoroughness of environmental hygienic cleaning should not also be optimized, particularly since such an intervention can be essentially resource neutral.

References

1. Hayden MK, Bonten JM, Blom DW, Lyle EA. Reduction in acquisition of Vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis 2006; 42:1552-1560.

2. Eckstein BC, Adams DA, et al. Reduction of Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infect Dis. 2007 Jun 21;7:61

3. Dancer SJ, White L, Robertson C. Monitoring environmental cleanliness on two surgical wards. Int J Env Health Res 2008; 18: 357-364

4. 195.92.246.148/knowledge_network/documents/Bioluminescence_20070620104921.pdf

5. Carling PC, Parry M, Rupp, M, Po JL,DickB, Von Beheren S. for the Healthcare Environmental Hygiene Study Group. Improving Cleaning of the Environment Surrounding Patients in 36 Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:11,035-1041