november 9, 2017 stanford university medical center...

PRESENTED BY

NOVEMBER 9, 2017 Stanford University Medical Center Palo Alto, CA

Exposure Concerns Related to Disinfection Techniques Erica J. Stewart, HEM, CIH, FAIHA® NEH&S Principal Consultant Kaiser Permanente

Allison Jouras, ASP, HEM Senior Consultant BSI EHS Services and Solutions

© 2017 EHSSENTIALS

Exposure Concerns Related to Disinfection Techniques

Agenda • Kaiser Permanente Case Study • Protecting our people when considering a new

disinfectant

© 2017 EHSSENTIALS


Objectives

Be aware of items to

consider when planning the

roll-out of a new disinfectant

Recognize organizational barriers that

may exist when implementing a new disinfectant

Understand the considerations

when comparing two

disinfectants

Selecting Surface Disinfectants: A Case Study

Erica J. Stewart, HEM, CIH, FAIHA® NEH&S Principal Consultant Kaiser Permanente

© 2017 EHSSENTIALS


A Tale of Two Towelettes • Ready-To-Use 0.63% sodium hypochlorite pre-wetted

disposable towelettes dispensed from a canister with a small aperture top opening

• Improved hydrogen peroxide (HP)/peroxyacetic acid (PAA) disinfectant diluted in a closed system to ~ 0.9% HP, 0.2% PAA, and 0.25% acetic acid and dispensed onto microfiber reusable towelettes in a covered bucket

© 2017 EHSSENTIALS


Efficacy • Table A.1 “Comparison of Contact Time and

Temperatures for Species of Interest” • Data from:

– Literature – Product testing results – Product specifications – US EPA registration

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8

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9

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C. diff.

Disk Carrier Test Method Efficacy of liquid sporicides on non-porous and porous surfaces

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Effectiveness • Influenced by:

– Wiping method (pressure, time, motion) – Disinfectant load on wipe – Surface type and condition – Surface characteristics – Wipe materials

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Effectiveness (cont’d.) • Limited information published • No standardized effectiveness test method • Differences among surface and wipe types • Lab testing vs. field application • Variation in cleaning methods

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Efficiency (Cost-Effectiveness) • Cost per wipe • Pre-cleaning step, post-disinfection rinse? • Dwell time (reapplication?) • Surface material compatibility

© 2017 EHSSENTIALS


Bleach vs. HP/PAA • RTU bleach wipes easier to deploy • HP/PAA does not require pre-cleaning or rinsing • RTU bleach shorter dwell time • HP/PAA not corrosive to surfaces • Both have health & safety considerations

© 2017 EHSSENTIALS


Health & Safety Considerations • Table A.2 “Occupational and Environmental Health and

Safety Parameters” • Data from:

– Literature (including online databases) – Safety data sheets – Product testing results – Product specifications – US EPA registration

© 2017 EHSSENTIALS


• Pros – RTU convenient – Staff acceptance – Minimal eye and skin toxicity – Not ignitable, reactive, or toxic

waste

• Cons – Inappropriate personal care use – Pre-cleaning step – Respiratory system asthmagen – Corrosive waste, oxidizer – Surface incompatibility requires

rinse – No established OEL or

monitoring method

Bleach Wipes

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• Pros – One-step cleaner/

disinfectant – Reusable towelettes – Not a sensitizer – Not corrosive, ignitable,

reactive, toxic waste – Established OELs and

monitoring methods

• Cons – Dilution of concentrate

(concentrate has severe hazards)

– Staff acceptance (not) – Respiratory system

asthmagen? – HP may be carcinogenic – oxidizer

HP/PAA Wipes

© 2017 EHSSENTIALS


• Bleach

• HP/PAA (unpublished) – HP <5% 8-Hr OSHA PEL – PAA ~50% ACGIH TLV

Air Monitoring Data

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Health & Safety Considerations • Personal factors • Spill and splash potential • PPE selection • Face/eyewash availability • Disposal

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Conclusions?

Selecting Surface Disinfectants: Protecting Our People

Allison Jouras, ASP, HEM Senior Consultant BSI EHS Services and Solutions

© 2017 EHSSENTIALS


Selecting a New Disinfectant

Need to use to prevent patient

infections Cannot use at the expense of staff

safety

© 2017 EHSSENTIALS


Selecting a New Disinfectant

- Patient and employee safety - Infection rates - Ease of use - Staff and patient perception of cleanliness and hazardous properties - Regulatory compliance

Many priorities to take into consideration:

- Environmental Services (EVS) staff

These may seem independent of one another, but there is a common thread:

© 2017 EHSSENTIALS


How Priorities Are Affected by EVS Patient and employee

safety

Infection rates

Ease of use

Staff and patient perception of

cleanliness and hazardous properties

Regulatory compliance

• Slips/Trips/Falls • Hazardous exposures • Body mechanics during use

• Correct use of product

• Staff more likely to use product correctly if it is easy to use

• Staff talk amongst themselves and others • Facial expressions and behaviors

indicating concern/dissatisfaction with product use

• Storage, use, and disposal • Spill response

© 2017 EHSSENTIALS


The Balancing Act

How do we make sure everyone goes home safely at the end of the day?

Execute a proactive roll-out and plan for reactive response

© 2017 EHSSENTIALS


Proactive Roll-Out: Evaluate Your Current State

Procurement process: • What gaps could lead to a new disinfectant

showing up onsite without EH&S knowledge? • Does EVS workflow for reviewing new disinfectants

involve EH&S?

EVS and EH&S: • Does EVS see EH&S as a resource or a barrier? • Does EVS understand what role EH&S plays in

regards to their operations?

© 2017 EHSSENTIALS


Proactive Roll-Out: Evaluate Your Current State

• Why risk assessments for each product are crucial to staff safety? • That vendor messaging about safety hazards and safety measures does not equal

EH&S review? • That vendor safety training does not equal EH&S safety training? • That EH&S is advocating for EVS staff safety?

EVS and hazards - Does EVS management understand:

• Do they see infection rates and patient safety as more important or equal to employee safety?

• What role does EH&S have in approval of product for use at your medical center in relation to IC and EVS?

• Is EH&S empowered to stop product use if there’s an unmitigated safety risk?

Infection Control (IC):

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Proactive Roll-Out: Risk Assessment

Question the Safety Data Sheet

(SDS)

Are hazards appropriately represented? Hold vendor and manufacturer accountable

Ensure risk assessment

process represents life-

cycle of product at

your institution

Arrival, transport within the facility, storage, concentrate vs.

diluted solutions, access controls, spill response, disposal

of concentrate and diluted solutions, etc..

© 2017 EHSSENTIALS


Proactive Roll-Out: Risk Assessment

•Gemba/tabletop proposed product use with the vendor, EVS, and IC •Point of entry onsite through disposal •Bring product onsite for demo of use by vendor •Experience product use as EVS staff will •Include all vendor-provided equipment necessary for product use (e.g. dispensing stations)

Involve IC and EVS in Risk Assessment process:

•Conduct your own risk assessment though

Benchmark with similar institutions:

•“The diluted solution is safe for staff to handle without gloves on” •May need to educate the sales rep/vendor about hazards

Be aware of vendor messaging related to safety risks:

© 2017 EHSSENTIALS


Proactive Roll-Out: Safe Handling and Use Reference materials and

safety postings Establish expectations for what materials shall

be at point of use and access to training materials

Identify what will need to be created, who will be responsible for doing so, and establish

reference material expectations

Make posting/access to reference materials a condition for use

Personal Protective Equipment (PPE):

Concentrate and diluted solution

Use and storage areas

Transport throughout facility

Safety showers and eyewashes

© 2017 EHSSENTIALS


Proactive Roll-Out: Safe Handling and Use

EVS staff training: • Language barriers for English-as-a-second-

language speakers • Comprehension of how to use the product

vs. comprehension of safety-related information

• Unjustified fears arise from lack of information/comprehension

© 2017 EHSSENTIALS


Proactive Roll-Out: Safe Handling and Use • EVS staff training:

– Vendor training vs. EH&S training requirements • Vendors may provide EVS training materials that “include all required safety

information” – Incorporate mandatory EH&S training review – Ensure EH&S is on-hand at all trainings to answer safety-related questions

• Incorporate rounding in the initial days after implementation to verify safe handling and use

• Address what harmful exposure really means for that product • Unit and Physician messaging

© 2017 EHSSENTIALS


Reactive Roll-Out: Anticipate Issues As Best You Can

Create action plans as necessary for anticipated issues: •Media plays to

people’s fears so see what’s available to the public

Benchmark with other institutions

about what issues they’ve encountered

Identify staff confidantes and

stay in communication

with them

Determine if proactive exposure

sampling may be worth the

investment

© 2017 EHSSENTIALS


Summary Remind colleagues that

the goal is to ensure that everyone goes home

safely at the end of the day (staff and patients)

Include colleagues in the risk assessment process

Address the life-cycle of the product

Question the product materials if they seem

inadequate

Ensure staff training is adequate and can be

comprehended

Try to anticipate issues, but we can’t anticipate

everything

© 2017 EHSSENTIALS


Thank you for your time! • [email protected] • [email protected]

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november 9, 2017 stanford university medical center...

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