Is Your Facility Clean? DAZO Knows

1. Is Your Facility Clean?DAZO Knows Sandra Von Behren TSICP

2. 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 TSICP

3. Philip C. Carling, MD • Boston University School of Medicine • Department of Epidemiology,Carney Hospital • Boston, MA TSICP

4. 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 TSICP

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

6. Environmental Contamination with Antimicrobial Resistant Organisms (MDROs) Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

7. Environmental Contamination with Antimicrobial Resistant Organisms (MDROs) 39 % of positive cultures from staff only touched objects were different from those for which the patient was being isolated Adopted from – Speck SHEA Abstract 167, Baltimore, April 2007

8. Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour Adapted from - Hardy KJ et.al J Hosp. Infections 66,360 August 2007

9. C. Difficile Environmental Contamination Mutters R, etal. J Hosp Infect. 2009; 71: 43-48

10. 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

11. C. difficile Transmission From Prior Room Occupants Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

12. C. difficile Transmission to Prior Room Occupants 110% Increased risk Shaugnessey etal. Abstract K-4194 IDSA / ICAAC. October 2008

14. HCW HANDS ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS

15. HCW HANDS ISOLATION ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS

16. HAND HYGENE HCW HANDS ISOLATION ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS

17. HAND HYGENE HCW HANDS ISOLATION ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS ENVIRONMENTAL SURFACES

18. HAND HYGENE HCW HANDS ISOLATION ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS ENVIRONMENTAL SURFACES

19. HAND HYGENE HCW HANDS ISOLATION ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS SUSCEPTABLE PATIENTS ENVIRONMENTAL SURFACES DISINFECTION CLEANING

20. Prevent Transmission:Hand Hygiene • Many facilities have had significant improvements • Microbial resurgence is rapid following HH • Logistical limitations in a complex environment TSICP

21. HH in Complex Intense Environments is Very Difficult 30 to 40 HH “Moments” per Hour during direct patient care

22. Isolation • Difficult to implement and maintain • When to Begin—When to stop • Unintended consequences TSICP

23. Isolation is Difficult

24. 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

25. What can we do?? Improve effectiveness of environmental cleaning/ disinfection patient environment

26. How Can We Evaluate Environmental Cleaning • Direct observation • Culture the environment • ATP bioluminescence Tool • Fluorescent marking tool TSICP

27. 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.

28. 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

29. 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

30. Evaluating Patient Zone Environmental Hygiene

31. Evaluating Patient Zone Environmental Hygiene

32. Evaluating Patient Zone Environmental Hygiene

33. Evaluating Patient Zone Environmental Hygiene

34. GOAL OF THE PROJECT To develop a surrogate marking system to evaluate the effectiveness of environmental cleaning/disinfection of the near-patient environment

35. Dazo Solution(Initially called “GOO”)

36. Target After Marking

37. Target Enhanced

38. 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

39. Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated Phase I: Covert Baseline Environmental Cleaning Evaluation Terminal cleaning after 1 or 2 patient cycles Cleaned, empty room identified Room marked Room evaluated Phase II: A. Programmatic Analysis B. Educational Interventions – ES staff Phase III: Re-evaluation of Cleaning and feedback to ES

40. Preliminary Results – Three Hospitals Clinical Infectious Diseases – February 2006

41. The Healthcare Environmental Hygiene Study Group 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

42. Healthcare Environmental Hygiene Study Group – Acute Hospitals (90) MA = 12 RI = 5

44. Baseline Environmental Evaluation of 36 Acute Care Hospitals Mean = 48.5 % Hospitals (20,056 Objects) % of Objects Cleaned

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

46. Terminal Room Cleaning Project – Three Programmatic Responses 17 HOSPITALS 10 HOSPITALS 8 HOSPITALS

47. Hospitals Environmental Hygiene Study Group36 Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTION Resource Neutral P = <.0001

48. Specific Opportunities for Improvement • TERMINAL ROOM CLEANING • INFECTION PREVENTION • TARGETS • Sink and Faucets • Toilet Surfaces • Toilet Flush Handle • Bedpan Cleaner • Toilet Area Handholds • Toilet Area Door Knobs or • Push Plates • Bedside Table • Tray Table • Patient Chair • Side Rails • Room Door Knobs • Call Box • Telephone • Bathroom Light Switches

49. 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 TSICP

50. Focus Group Questions • What recommendations do you have to improve cleaning outcomes? • What barriers do you see that would prevent implementation of these recommendations? TSICP