emerging trends in healthcare pat vanko - johnsondiversey

3. To Clean or Not to Clean��

4. Cross Contamination CDC - Hard surfaces generally not directly associated with transmission of infections to staff or patients - Hand contact with the surface - Cleaning/disinfecting of surfaces is fundamental in prevention of healthcare associated infections

5. Degrees of Clean Environmental Cleaning Sanitizing Disinfecting Sterilizing

6. Environmental Cleaning Basic Level of Clean Can�t kill if you don�t clean Removes many of microbes that are growing on or in soil Does not control any one microbe Recommend a general purpose cleaner

7. Importance of Cleaning Makes good business sense � dividends returned for investment in sanitation - Furnishings last longer when properly cleaned - Healthy environment - Productive work area - Safety - Fire Prevention - Public relations - Improved customer relations - Disinfectant (removal of gross soils required)

8. Disinfecting Patient contact surfaces, surgical & clinical surfaces, restrooms and nursing stations Contains an active ingredient One-Step (Cleans & Disinfects) Kills microbes Tested using AOAC Use Dilution Test

9. Sanitizing Used in foodservice areas Clean first, rinse Reduce bacteria to a safe level WASH RINSE SANITIZE AIR DRY

10. Sterilizing Highest level of clean All organic & inorganic microorganisms and spores destroyed Required for surgical instrumentation Requires heat or extended contact with strong chemicals to control/kill microbes and spores Not required for housekeeping procedures

11. Selection of Disinfectants Based on needs within facility Judgment � guided by label Medical devices regulated under FDA & EPA AOAC Use Dilution Test Hospital Grade Disinfectants Shelf life of use-dilutions

12. Types of Disinfectants Quaternary Ammonium Compounds Phenolic Compounds Alcohols Bleach Iodophors

13. Quaternary Ammonium Compounds Advantages Broad spectrum of kill Excellent cleaner Low cost Low acute toxicity in use dilution Hospital Grade Disinfectant � dependent upon formula & efficacy package Technology readily available Disadvantages Does not Kill Tb Effectiveness limited by presence of organic substances Absorbed by cotton Some quats limited by anionic cleaners

14. Phenolics Advantages Effective against broad spectrum of microorganisms Kills Tb Low toxicity in use dilution Disadvantages Poor cleaner � compatible with anionic detergents Cannot be used in neonatal area Inactivated by hard water & organic matter if not formulated properly Residual film can accumulate on floors Accurate dilution critical for germicidal activity Skin depigmentation possible

15. Bleach Advantages Inexpensive and readily available Effective against a broad spectrum of micro-organisms Disadvantages Inactivated by organic matter e.g. blood Strong odor Mixing of chlorine & ammonia based cleaning agents will emit highly toxic gas Concentrations at >1:100 are corrosive to metals Shelf life in diluted form is limited Sensitive to heat & light

16. Alcohol Advantages Broad spectrum of kill Readily available Dual use � antiseptic & disinfectant Effective disinfectant for clinical tables, counters & medical equipment Disadvantages Evaporates quickly � possible insufficient contact time Can damage rubber & plastic Volatile & flammable

17. Iodophors Advantages Broad spectrum of kill Time-sustained antimicrobial activity Easily combined with detergents or other surfactants Disadvantages Fair to poor cleaners Inactivated by presence of organic substances Stains porous substrates Can be irritating to eyes and throat Potentially corrosive to metals

18. Selecting the Right Disinfectant Type of Soil Some soils demand an acid type product (rust, lime scale, hard water deposits) Some soils demand an alkaline product (grease, oil, protein, smoke) Amount of soil Surface to be Cleaned Cleaner should be strong enough to remove soils Pre-test in inconspicuous area Pre-cleaning may be necessary Method of Application Review label Spray, mop & bucket, equipment (automatic equipment) Poured (Bowl Cleaners) Proper Dilution Rate Measuring device Dispensing equipment

19. Understanding Disinfectants Different types of disinfectants - high-level - intermediate-level - low-level Decision must be made to match disinfectant and procedure to the task and to the microorganism

20. Levels of Disinfection High-level � sporicidal chemicals (glutaraldehyde, peracetic acid, hydrogen peroxide) not appropriate for use on housekeeping surfaces, can be highly toxic Intermediate-level � Inactivates Tb (sodium hypochlorite (chlorine), alcohols, some phenolics & idophors) Low-level � hospital disinfection w/o Tb claim Antiseptics � FDA approved, not appropriate for use as environmental surface disinfectants

21. EMERGING DISEASES Tb Bloodborne Pathogens SARS Avian Influenza MRSA VRE C.Diff

22. Tuberculocidal Disinfectants Do not interrupt or prevent transmission of Tb Not acquired from environmental surfaces Benchmark OSHA�s Bloodborne Pathogen

23. Bloodborne Pathogens No evidence that BBP has been transmitted from floor, wall or countertop HIV & HBV readily inactivated with disinfectants including quats Products to use - Sodium Hypochlorite - EPA registered product with Tb claim - EPA registered product with both HIV and HBV

24. MRSA/VRE Antibiotic Resistant Organisms - MRSA & VRE - transmitted patient to patient - indirectly hands of healthcare worker - hand transfer from environmental surfaces & patient care equipment - VRE can persist on dry surfaces from 7 days to 4 months - VRE recovered from inoculated health worker�s hands (with or without gloves) for up to 60 minutes - Control of MRSA, VRE, VISA - Enforce hand washing and use of barrier precautions to minimize spread - Cleaning of patient/resident rooms & medical equipment - Routine cleaning with either low or intermediate disinfectant cleaners - No need to increase dilutions of disinfectant cleaners - Follow label directed use

25. Special Pathogens Clostridium Difficile - Successful measure to control spread has been restriction of antimicrobial agents - Little evidence especially housekeeping surfaces (floors, walls) that environment is direct source of infection - Direct exposure to contaminated patient-care items (rectal thermometers) - High-touch surfaces in patients� bathrooms source of potential infection - Most likely mechanism of exposure is healthcare workers hands - Colonized patients may also service as a source for contamination - Use of chlorine containing products showed reduction on environmental surfaces - Recommendations for control - meticulous cleaning, followed by disinfection

26. Norovirus Norwalk Virus � Feline Calicivirus Family Unable to grow Norwalk in Lab Requires surrogate EPA announces surrogate - 2004

27. Norwalk - Transmission Hands (39%) Mouth (12%) Air Hard Surfaces Food Water

28. Critical Characteristics Highly contagious Multiple modes of transmission Stabile in the environment Resistant to routine disinfection methods Limited immunity Asymptomatic

29. Routine Cleaning of Housekeeping Surfaces Regular cleaning is required Use soap and water or a detergent/disinfectant - Nature of surface - type and degree of contamination Surfaces can be divided into two categories - Minimal hand contact � floors, walls - Frequent hand contact � doorknobs, bedrails, switches, restroom areas (fixtures, walls around the stools)

30. What is �Bird Flu�, Avian Influenza? Causative agent: (Avian) Influenza A, subtype H5N1, a member of the family Orthomyxoviridae. www.fao.org/ag/againfo/subjects/en/health/diseases-cards/avian.html Transmission: The virus is excreted from infected birds via feces, nasal or ocular discharge which then infects new birds via conjunctival, nares or the trachea. The virus has been isolated from feed, water and soil as a result of cross contamination. The virus has been transmitted to humans via direct handling of an infected bird or in contact with an infected farm. Airborne transmission is also a possibility. www.fao.org/ag/againfo/subjects/en/health/diseases-cards/avian.html Stability: �The virus can survive for extended periods in the tissues and feces of infected birds. In water, the virus can survive for up to 4 days at 22 deg C and more than 30 days at 0 deg C.� www.who.int/csr/don/2004_01_22/en/

31. Regulatory Recommendations - WHO �Good hygiene practices during handling of poultry products, including hand washing, prevention of cross-contamination and thorough cooking (70 deg C).� www.who.int/csr/don/2004_01_24/en/ Stringent sanitary measures on the farm, including disinfection of contaminated farm equipment, transport vehicles, and cages. www.who.int/csr/don/2004_01_15/en/ �Quarantining infected farms, destruction of infected or potentially exposed flocks and feed.� www.who.int/csr/don/2004_01_15/en/

32. Recommendations for Avian Influenza Precautions: Hand hygiene before and after patient contact or with items contaminated with respiratory secretions Use gloves & gowns for patient contact Use dedication equipment (blood pressure cuffs, disposal thermometers, etc.) Wear eye protection within 3 ft of patient Place patient in airborne isolation room (negative air handling) HEPA filters if negative air handling unavailable. Use fit test respirator � NIOSH Vaccination of Health-Care Workers with recent vaccine

33. Breaking the Chain through Effective Cleaning Use appropriate cleaner/disinfectant Apply liberally Give proper contact time Shelf life of diluted products Disinfect and clean equipment and receptacles (sharp, sanitary napkin, and trash containers) Keep equipment clean (buckets, trigger spray bottles, dispensing equipment) Dispose of contaminated cleaning materials Clean frequently touched public surfaces Keep pests and rodents out of your facility Keep kitchen, refrigerators and all food contact surfaces cleaned and sanitized

34. Directions for use of disinfectant Use Product according to label Contact times Dilute accurately (more is not better) Apply liberally Surface should be visibly wet for recommended contact time High soil loads may require precleaning Soils provide food source

35. New Actives Drug Resistant Organisms Shorter Contact Times Rumblings in industry that microorganisms becoming resistant to quats One product to do all

36. Hydrogen Peroxide Advantages Can enhance removal of organic matter & microorganisms No disposal issues No odor or irritating fumes At higher concentrates (1:16) � lower contact times Disadvantages Incompatibility with some metals Eye damage High concentration required at end use dilution (1:16) for disinfecting

37. Peracetic Acid Advantages Compatible with a wide variety of materials & instruments Sporicidal properties Rapid sterilization (30-45 minutes) Disadvantages More expensive than high level disinfectants Not compatible with aluminum

38. Silver Ion Formulated with Silver & Quat Provides various contact times � 30 seconds to ten minutes Residual � 24 hours Ready to use

39. Looking Ahead Key People in the industry and academia are saying �the future of cleaners will be in non-halogen based oxidizers.� What are the desired traits in these futuristic cleaners?

40. Desired Traits Non-toxic to humans & animals Non-allergenic & non-sensitizing Non-hormone disrupting Environmentally sound Low Volatile Organic Compounds (VOC) Longer shelf life Safe to transport Safe and easy to store Non-corrosive Compatible with today�s and tomorrow�s new materials (flooring, countertops, plastics, equipment, etc)

41. On-Going Innovation Higher concentrations Use more of less Products that are safe to the environment Green Seal certified products Little or no impact on the environment or indoor air quality Less hazardous to people - Products with little to no impact on human health - Dispensing systems � no contact with concentrated chemicals More synergistic actives Improved performance Performs multiple cleaning processes in one step

42. What�s Next Cleaning trends are moving towards minimization: - Products will be required to perform multiple tasks - Little or no impact on the environment, animals or humans - Automated cleaning systems - Programmed to clean at specific times - Detection of soiled surfaces - Self-cleaning surfaces that degrade soils or prevent soil from adhering

43. Disinfectant Product Labels EPA Registration Number Label Claims Actives Product Uses Test Method Contact Time

44. Handwashing Is important to prevent spread of disease Wash hands frequently with soap and water Use alcohol-based handrubs when hands are not visibly soiled Wash hands for 15-20 seconds Wash hands after removing gloves Dispose of gloves Reusable gloves � follow facility guidelines

45. Carpeting ADVANTAGES Noise Reduction Humanizing Contributes to reduction of falls

46. Carpeting DISADVANTAGES Difficult to keep clean (spills) Harder to push equipment (wheelchairs, carts, gurneys) Increased activity levels increase bacteria counts

47. Carpeting Despite bacterial growth � �little epidemiologic evidence to show that carpets influence healthcare-associated infection rates in areas housing immunocompetent patients� �Guideline includes no recommendations against the use of carpeting in these areas�

48. Carpet Maintenance Care to prevent dispersal of carpet microorganisms into the air - maintain equipment - use of HEPTA filters in high-risk patient-care areas - carpet cleaning chemicals - powder & liquids - TOTAL PROGRAM REQUIRED

49. Mold & Mildew Conditions Remove source Products available Construction

50. Microfiber Blend of microscopic polyester and polyamide fibers Due to fine filaments the microfiber loosens dirt even in the smallest structures (mechanical action) Capillary force of the micro fiber textile absorbs large amounts of loose dirt and/or soiled solution

51. Microfiber Advantages Reduce chemical use and disposal Reduce cleaning times for patient rooms or other high use areas Prevents dirty mop heads from contaminating clean solutions Cleans � removes soils that microorganisms feed on Clean solution each time tool/microfiber pad is used

52. Wipes Require EPA registration Wet Task System Shelf life