Vicki Brinsko Director Infection Prevention & Control

Vanderbilt University Medical Center

*Although I am conflicted when it comes to Pumpkin Spice Latte

Promote a safe, functional, and supportive environment within the hospital so that quality and safety are preserved.

The building or space, including how it is arranged and special features that protect patients, visitors, and staff Equipment used to support patient care or to safely operate the building or space People, including those who work within the hospital, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks

20 standards that cover Minimizing risks to the EOC Safety & security Smoking Hazardous waste Fire Medical equipment Utilities Construction

143 elements

Maintaining a safe environment of care

EC 02.02.01 manages hazardous waste and materials EC 02.03.01-05 fire and fire safety EC 02.05.01manages risks with utility systems EC 02.05.03 reliable emergency electrical power source EC 02.05.05 inspects, tests, maintains utility systems EC 02.05.09 inspects, tests, maintains medical gas and vacuum systems EC 02.06.01 maintains safe environment EC 02.06.05 manages environment during demolition, renovation or new construction

Joint Commission (2014).

Access to Safety Data Sheets Safe storage of hazardous chemicals

Sharps Infectious waste Other hazardous wastes

Right to know which chemicals in the environment are hazardous

Staff should know how to find SDS Staff should know where Safety Manual located

Every container must have Name of product Hazard warnings (flammable, corrosive, poison, etc.)

Check on housekeeping carts for unlabeled spray bottles (cleaners), micro fiber mops in cleaning chemical Check under sinks for

Storage violations Unlabeled and improperly stored chemicals

Categories of Infectious Waste

Contaminated sharps Microbiology/stock cultures Animal wastes research labs Blood and blood products Isolation waste Pathology waste

Non-included waste paper products, over wraps, food Other types:

Chemical Pharmacy Radiological

One study on how long Ebola lasts in environment=6 days (lab)

Inactivated by UV or drying Real world cultures= No growth

Waste generated during delivery of care to Ebola virus-infected patients would not be subject to Federal select agent regulations Handle waste per usual isolation patient (CDC, 2014)

One study on how long Ebola lasts in environment=6 days (lab)

Inactivated by UV or drying Real world cultures= No growth

Waste generated during delivery of care to Ebola virus-infected patients is subject to Federal select agent regulations Chain of custody required with a manifest (CDC, 2014)

Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., norovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infection.

Bleach (fresh) 1:10 Bleach wipes Quat wipes with adenovirus or norovirus label claim

(CDC, 2014) Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus

Some waste haulers are classing isolation waste from Ebola patients as Class A (CDC Class IV) infectious agents Package waste as follows:

Double bag in red biohazard bags Place in rigid container

Your waste hauler may require that this waste be sterilized or rendered non-infectious prior to pick up

Autoclave Incinerate Disinfect with disinfectant solidifiers

(CDC, 2014)

If you do not have the means to render the waste non-infectious, store it 55 Gal barrels provided by vendor seal bags of waste inside

No storage within 18 inches of sprinkler head Exit corridor must have egress

Some things can be stored in the hall; choose a side Isolation carts exempt

Exit signs must be accurate and in working order Fire extinguishers are present and checked monthly

Critical fire doors are self or automatic closing Cannot be propped open

No wedges No rope, ties, kerlex No objects (especially O2 cylinders)

If needed to stay open use magnetic latch (released during alarm) or other installed device

but NO

Seriously?

Improperly stored O2 cylinders can fall and become a torpedo propelling and possibly exploding on impact Store in proper holders Store large cylinders chained

Many hand sanitizers contain alcohol In corridor if sprinkler system present Not in carpeted area No ignition source

Directly below or either side Ignition sources: outlets, light switches, thermostats, any electric equipment

Electric, Water, HVAC

Facility Guidelines Institute (FGI) and American Institute of Architects (AIA) new in 2014

American Society of Heating, Refrigerating, & AC Engineers (ASHRAE) NIOSH and CDC requirements for negative pressure rooms

Negative Pressure Isolation Room

Air flows in from outside corridor.

Air leaving room goes through HEPA filter.

Filtered air is safe to breathe.

National Fire Protection Association (NFPA) Center for Medicare and Medicaid (CMS) State OSHA (TOSHA) TB but also waste anesthesia gases EPA emissions from incinerators, ETO sterilizers and indoor air quality (mold)

Area Description Pressure # Outside Air Exch Min # Air Exch Patient Room - 2 6 Airborne Isolation Room

Neg 2 12

OR Pos 3 15 Trauma Room (ED)

Pos 3 15

Bronchoscopy Neg 2 12 Cardiac Cath Pos 3 15 L&D Pos 3 15

Adapted from Olmstead, 2014

At least yearly reports on air exchanges in OR and procedure areas Negative pressure rooms should be checked daily Positive pressure rooms with HEPA filtration should be at least yearly Should be presented at Infection Control Committee

Dialysis water checks Dental water checks HVAC water checks/treatment and controlling for Legionella Flooding and water leakage

Faucets no touch linked with legionella contamination (Dickey, 2014)

Location of sinks convenient to use Soap dispensers should be with disposable cassettes Aerators- avoid

Avoid water features in hospital settings Treatment follows a single case on healthcare associated Legionella

Involve the health department Epidemiologic investigation If ongoing transmission environmental cultures Water treatment

Improper water treatment system design Loop Holding tanks UV/Ultrafilters

Improper maintenance of water treatment system and delivery system (dialysis machine)

Disinfection schedule Improper disinfectant

Risk Assessment for projects, demolition, renovation, major construction Look for shutting off return air flow from construction or renovation site with filter medium Minimize dust

The object is to obtain negative pressure in the project whenever feasible. By sealing off supply and filtering the return duct, negative pressure can be achieved. (Less dust leaving the project). Sometimes, in higher risk areas, it is necessary to obtain negative pressure by use of a HEPA unit. Negative pressure is monitored on Class IV projects by use of a manometer.

Project  Info  

Construction  Activity  Type  

Infection  Control  Risk  Group  

Infection  Control  Class  

Comments  &  Signatures  

The  Infection  Control  Class  is  determined  by  where  the  Project  Type  and  Infection  Control  Risk  Group  intersect  in  this  Matrix.  

I   I   II   III/IV   Infection  Control  Class  

I   II   III   IV  II   III/IV   III/IV   IV  

Construction  Project  Type  A   B   C   D  

Infection  Control  Risk  Group  

Low  Medium  High  

INPATIENT AREAS:

CLINIC AREAS: Hematology, Oncology, Infectious Disease, Transplant Services. SERVICE AREAS: Central Processing, Sterile Processing, Food Prep and Service Areas, Pharmacies.

Depending on your location in the hospital or clinics, popping open just one ceiling tile could release enough dust to cause infection in a patient. Always play it safe, fill out a permit and follow all applicable IC measures!

Small scale activities other than inspection located above the ceiling grid are considered Type B work. Type B work in a low risk area = Class I requirements (clean up area after work is complete, immediately replace tile) Number of ceiling tiles removed are not to exceed one (1) ceiling tile for every 50 square feet or one (1) ceiling tile for every 10 linear feet, whichever is less. Type B work in a medium risk area Class II requirements (use containment cube and follow Class I requirements) Type B work in a high risk area Class III/IV (have meeting with IC/VEHS before work begins to decide dust control requirements)

There is a new policy for mold remediation activities found at: vumcpolicies.mc.vanderbilt.edu Mold can be serious depending on the become airborne. Immediate action is required.

In this picture there is an excessive amount of

Check equipment for maintenance (sticker system, etc.,) Make sure staff understands how to clean the equipment (and when to clean) If you have a policy on frequency of

followed

Some take 5 10 minutes to totally kill the pathogens (on the label) Potential reactivity with acids and other chemicals that produce toxic fumes Deactivation through contact with organic matter Irritation to eyes, skin, respiratory tract

Coagulase negative staphlyococcus Staphylococcus aureus Enterococcus species Candida species E. coli Pseudomonas aeruginosa Klebsiella pneumoniae Enterobacter species Acinetobacter baumannii Klebsiella oxytoca Other Sehulster, Chinn, and HICPAC 2003

Spores

Mycobacterium

Nonlipid Viruses

Fungi

Vegetative Bacteria

Lipid Viruses

High resistance

Low resistance

Spores

Mycobacterium

Nonlipid Viruses

Fungi

Vegetative Bacteria

Lipid Viruses

High resistance

Low resistance

Bleach

Quat

Phenol

Joint venture with EVS, IC&P and Nursing to determine who cleans what Write it down

List Policy SOP All of the above

Label claim is too long to be practical (most EPA registered products) 10 minute kill time requires product to be reapplied 5-6 times Typical air dry timing is 1.5 2 minutes Moral: thoroughness of cleaning to ensure all surfaces are wipes AND choose products with less kill time on label EPA will consider shortened time

Studies measured efficacy of disposable wipes (Guh, 2010)

Wipes play a role in decreasing surface contamination DO NOT Re-use on more than one surface Discard immediately

Temperature checks and documentation

Documenting variations and what happens if temp too low or too high

Labeling Patient food Biohazard/specimen Staff food

Keeping clean and dirty separate

Advantages Costs less and reduces waste Strictly regulated by FDA

Third party vendor preferred

Cleans and sterilizes Tests for functionality

Staff must know what to do

Collection for reprocessing Bins, containers for storage until pick up

Must have policy

Minimizing risks

Documented training Drills Staff and licensed independent practitioners can describe or demonstrate how to report environment of care risks.

Ensure basic safety training Ensure specialized training for disinfection/sterilization, etc Bloodborne Pathogen training Hand Hygiene/Infection Control Influenza Mountain States Health Alliance

Immunization programs

Influenza Vaccine preventable diseases

Injury prevention programs Treating on the job injury

Slips, trips, falls Sharps injury BBP exposure

Routine surveys No set time limit Follow your policy VUMC does EOC surveys every 6 months

Cross train in all areas (not just infection prevention) This is a team activity - Take a couple of team mates

Say what you do and do what you say

Conduct EOC surveys when you say (in policy) that you will do them

Look for the obvious Use a checklist Feed back results to units/departments

Cross train teams to look for everything Tracers and chart audits can be done simultaneously or separately Feedback score to area manager Report scores to safety committee

CDC. (2014). Interim guidance for environmental infection control in hospitals for Ebola virus. Retrieved from http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html Chatman, I.J. (2009). Infection prevention and control issues in the environment of care (2nd Ed.). Oakbrook, IL: Joint Commission Resources Guh, A., Carling, P., (2010) Options for Evaluating Environmental Cleaning Retrieved from http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html Goodman, E.R., Platt, R,, Bass R, Onderdonk , A.B., Yokoe, D.S., Huang, S.S. (2008). Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol. 29(7): 593 599. Guh, A., Carling, P., (2010) Options for Evaluating Environmental Cleaning Retrieved from http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html Joint Commission (2014). Hospitals (CAMH). Retrieved from http://www.jointcommission.org/standards_information/hap_requirements.aspx Olmstead, R.N. (2014). Heating, ventilation, and air conditioning. In APIC Text of Infection Control and Epidemiology (4th ed., pp. 114-1-114-16). Washington, DC: APIC. Rutala, W.A., Weber, D.J. (2014). Selection of the ideal disinfectant. Infection Control and Hospital Epidemiology, 35, 855-865. http://dx.doi.org/10.1086/676877 Sagripanti JL, Rom AM, Holland LE. (2010). Persistence in darkness of virulent alphaviruses, Ebola virus, and Lassa virus deposited on solid surfaces. Arch Virol 155:2035-2039 Sehulster, L., Chinn, R., and HICPAC (2003). Guidelines for environmental infection control in health-care facilities. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm