Evelyn Cook, RN, CIC Duke Infection Control Outreach Network

1. Evelyn Cook, RN, CICDuke Infection Control Outreach Network Hygiene as a Clostridiumdifficile Infection Prevention/Control Strategy November 8th, 2013

2. Objectives • Describe the relationship between Clostridium difficile infection and healthcare • Discuss hygiene issues and recommendations related to: • Healthcare Environment • Healthcare Personnel • Patients and Families

3. Is Clostridium difficile A Problem???

4. Researchers studying epidemiology of healthcare-associated infections (HAIs) in community hospitals in the southeast U.S. found that rates of Clostridium difficile infections (CDI) surpassed infection rates for methicillin-resistant Staphylococcus aureus (MRSA). Becky Miller, MD, Duke Infection Control Outreach Network, Duke University.

5. Potential Routes of Transmission CONTAMINATED ROOM PATIENTS HANDS EVS HAND HYGIENE HOSPITAL ROOMS Spill

6. Clostridium difficile • Clostridium difficile is the most common cause of healthcare-associated gastrointestinal infections in the US • Antibiotic exposure highest risk for acquisition Pseudo-membranous colitis Normal Colon

7. Clostridium difficile • C. difficile spores can contaminate a variety of items and surfaces in the vicinity of colonized or infected patients and transmission from the environment via HCP has been demonstrated • Transmission to C. difficile has been linked to contaminated electronic thermometers used for obtaining rectal temperatures.

8. In terms of bacteria, environmental contamination with C. difficile has been reported to occur in areas near infected or colonized patients. Commodes, bedpans, blood pressure cuffs, walls, floors, washbasins, and furniture are commonly affected. The organism has also been found in low numbers on shoes and on stethoscopes, and hospital floors have remained contaminated with C. difficile for up to five months.

9. Kramer et al.BMC Infectious Diseases 2006 6:130   doi:10.1186/1471-2334-6-130

10. “We are still debating the role of the environment in HAIs for many reasons, including the obvious fact that pathogenic microorganisms are invisible, because there are aesthetic biases to conquer, pathogen detection is challenging; and there are no widely accepted methods of measurement based in science currently” -Stephanie Dancer, BSc, MBBS, MD, MSc, FRCPath, DTM&H, FRCP (ed)

11. The Role of Environmental Contamination and HAIs • Numerous studies have shown that hospital surfaces and frequently used medical equipment become contaminated by a variety of pathogenic and nonpathogenic organisms • However, the role of fomites and the inanimate hospital environment in the transmission of HAIs is controversial

12. Environmental Contamination with C. difficile • Survey of surfaces outside of the patient room for C difficile conducted in 2009: • 31% of physician work areas contaminated • 10% in nursing area • 26% of desktop computers • 100% percent of doorknobs and • 33% of portable computers

13. Attitudes, Beliefs, Education • One survey designed to elicit perspectives about their work from environmental services workers found: • 37% said they did not think the environment had germs that can cause disease • 100% thought their work was instrumental in upholding patient safety • 75% percent thought it mattered to patients if they did a great job • 100% intended to clean well

14. Environmental Hygiene • Medical devices, equipment and items used in healthcare should be decontaminated and disinfected according to their category of use: • Critical items require sterilization • Semi-critical items require high-level disinfection • Non-critical items require low or intermediate level disinfection

15. The Physical Environment (non-critical) • Looks can be deceiving… • A patient room may look clean on the surface but micro-organisms may remain • Potential infection of the next patient can occur and possible lead to mortality

17. A Closer Look… • Blood and other body fluids spilled in patient rooms may contain pathogenic micro-organisms. • Visible spills aren’t the entire problem though. • Micro-organismsare too small to be seen with the human eye and can live all over a patient’s room. • Transmission can occur by anyone entering the room and making contact with contaminated items.

18. Effective cleaning requires the physical removal of BOTH dirt AND micro-organisms

19. Physical Environmental Hygiene • Try to establish a routine for cleaning rooms in the same order every time • Focus time on high-touch problem areas • Ongoing staff education, periodic monitoring of performance and feedback of findings is essential to improvement.

20. Seeing is believing… Invisible cream, lotions and powders Places not clean will Glow under UV light Ultraviolet Light

21. Physical Environmental Hygiene Recommendations • Clean and disinfect surfaces likely contaminated on a routine basis, especially frequently touched surfaces • Use a US EPA-registered disinfectant • Microbiocidal activity against the pathogen • Use in accordance with manufacturer’s instructions

22. Physical Environmental Hygiene Recommendations • Because C. difficile spores are resistant to alcohol and commonly used surface disinfectants, use chlorine-based agents for disinfecting surfaces and equipment in the room

23. Physical Environmental Hygiene Recommendations • Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (e.g., at least daily) with a focus on frequently-touched surfaces (e.g., bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient

24. Medical Equipment/DevicesRecommendations • Develop and implement policies and procedures to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another patient

25. Medical Equipment/DevicesRecommendations • For patients on contact precautions, use dedicated disposable patient care items, such as pulse oximetry probes and blood pressure cuffs. If not available disinfect prior to use on another patient • Consider using dedicated single-patient use and other non-critical patient care items for patients with poor skin integrity

26. Summary Environmental Hygiene • Policies and Procedures in place for frequency of cleaning √ • Approved agents used (approved by your infection prevention oversight body) √ • Education provided to all staff including environmental services √ • Develop a process for monitoring (other than visible check) √ • Feed data back to all disciplines

27. What About “Human” Hygiene ??? Families and friends Healthcare personnel Patients

29. Major Embarrassment and Failure of Healthcare Providers

30. Hand Hygiene Practices in Healthcare Average percent of Compliance = 40%

31. Breaches and Why They Happen • Busy Schedules • Understaffed and overwhelmed • Adapting to Environment • Task oriented (focus on a specific patient care function) • Mistaken belief that it is not a problem and no one will be harmed

32. Personnel contaminate hands by performing “clean procedures” Nurses contaminate hands with 100-1000 CFU during such “clean” activities as lifting patients, taking the patient’s pulse, blood pressure, or oral temperature, or touching the patient’s hand, shoulder, or groin Why is HH Important?

33. Healthcare Personnel Hygiene • Transmission of C. difficile in healthcare settings occurs most commonly via the fecal-oral route following transient contamination of the hands of healthcare workers and patients and via contamination of the patient care environment.

34. When To Do Hand Hygiene? After Removing gloves!!!

35. What Should Be Used • Soap and Water: When hands are visible soiled and/or contaminated • Alcohol based waterless agent: If hands are not visibly soiled, or after removing visible material with non-antimicrobial soap and water OR

36. The Exception • Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007

37. Controversy??? • The CDI component of the SHEA / IDSA Compendium of Practice Recommendations to Prevent Healthcare-Associated Infections and the SHEA / IDSA Clinical Practice Guidelines for CDI recommend preferential use of soap and water for hand hygiene over alcohol-based hand hygiene products only in outbreak settings

38. What About Patients, Families and Visitors • Have signs posted at entrance to units to please use hand hygiene prior to entering unit and when leaving the unit • Patients should cleanse hands (or have them cleanse) prior to leaving room for procedures and/or therapy • Patients on contact precautions should have clean gowns etc. prior to leaving room for procedures and/or therapy

39. Families and visitors of patients on contact precautions should be instructed to adhere to the facilities policies on use of PPE • Families and visitors of all patients should be reminded to cleanse their hands prior to and when leaving the patients room

40. Family and Visitor Education • Provide a fact sheet to patient and family • What is CDI and how is it spread • Consider restricting for persons at high risk for acquiring CDI (on antibiotics or immunosuppressed). 4 • Hand hygiene • Gown and glove use • Environmental cleaning

41. SummaryHuman Hygiene • Appropriate hand hygiene, including when and how √ • Healthcare personnel, patient and family education √ • Appropriate placement of patient √ • Monitor compliance with all metrics √ • Feed data back to staff

42. References • Kathleen Meeham Arias, MS, CIC “Contamination and Cross Contamination on Hospital Surfaces and Medical Equipment”; Initiatives in Safe Patient Care • Kelly M. Pyrek “Experts Ponder the Big Issues in Environmental Hygiene"; Infection Control Today; September 2013-vol 17; No 9 • Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection: Erik R. Dubberke, MD, MSPH; Dale N. Gerding, MD • CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: 2007